\\^(.%\ 


pis 


Columbia  Bmbcngftp 

mtI)tCityot3Trlugork 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonherniaOOdowe 


/ 


y 


TREATISE  ON  HERNIA: 


A  NEW  PROCESS  FOR  ITS  RADICAL  CURE, 


ORIGIML  CONTRIBUTIONS  TO  OPERATIVE  SURGERY, 


NEW  SUROICAL  INSTRUMENTS. 


BY    GREENSVILLE    DOWELL,    M.D., 

Pkopessoe  of  StraGEEY  m  Texas  Medical  College  ;  Late  Peofessob  op  Suegeey  in  Galveston  Medical  Collegs 

POBMEELY  Peofessob  op  Anatomy  in  Galveston  Medical  College  ;  Subgeon  to  the  Medical  College 

Hospital  ;  Memeeb  of  American  Medical  Association  ;  Membeb  of  Texas  State  Medical 

Association;  MEireEB  op  Galveston  Medical  Society;  Honoeaby  Member 

op  Boston  Gynaecological  Society,  Etc.,  Etc.;  Etc. 


PHILADELPHIA: 

D.  G.  BEINTON,  115  SOUTH  SEVENTH  STREET. 
1876. 


Entered  according  to  Act  of  Congress,  in  the  year  1876,  by 

GREENSVILLE  DOWELL,  M.D., 

in  the  Office  of  the  Librarian  of  Congress,  "Washington,  D.  C. 


JAMES  A.  MOORE,  PEINTEK, 

1222  and  122i  Sansom  Street,  Philadelphia. 


PREFACE. 


The  following  work  is  upon  a  subject  which,  perhaps,  more  fre- 
quently tjian  any  other  in  surgery,  demands  prompt  action,  ana- 
tomical knowledge,  and  surgical  skill.  The  number  of  sufferers 
from  hernia  is  immensely  large,  and  too  often  the  inadequate  knowl- 
edge of  their  attending  physicians  leads  them  to  the  nets  of  the 
charlatans  who  advertise  trusses  and  bandages. 

Even  able  men  have  hesitated  at  performing  operations  for  the 
radical  cure  of  rupture,  so  frequently  has  disappointment  followed 
this  procedure.  The  author  believes  he  explains  one  in  this  volume 
which  will  be  found  to  present  the  minimum  of  risk,  and  to  proffer 
a  large  probability  of  success,  as  the  statistics  given  will  demon- 
strate. 


It 


TABLE  OF  CONTENTS. 


Page 


s,  or  they  are  without  Sacs 


Heknia — Rttptttee. — Cerebri;  Pulmonalis ;  Abdominalis;  Yesicis;  Sclerotici 
Hernial  Protrusions ;  General  Symptoms ;  General  Causes ;  Special  Symptoms 

Proportion  of  Hernias  to  Number  of  Inhabitants, 

Gravity  of  Disease, 

Classification  of  Abdominal  Hernia, 

Its  Stage  and  Line  of  Progress, 

Direction  of  the  Protrusion,     . 

Positions  in  Abdominal  Hegion, 

Contents  of  a  Hernial  Sac, 

Mobility  of  Tumor  in  Cases  of  Hernia, 

Causes  Producing  Hernia, 

Dycotal  Table  of  Hernia,  . 

Sizes  of  Hernia, 

All  Hernias  have  either  Sacs  with  other  Coveringi 
or  Coverings,  .  .        .    - 

Compound  Contents,  ...... 

General  Predisposing  Causes — Inciting  Causes  and  Exciting  Causes, 

Anatomy  and  Structure  of  Hernia,  .... 

Reducible  Hernia  in  General.    Symptomatology,     . 

Treatment  of  Reducible  Hernia,  .... 

Various  Styles  of  Trusses,        ....... 

Radical  Cure  of  Hernia.     Process  by  Truss, 

Other  Methods  and  Processes.     1.   Cutting  out  the  Sac ; 
3.  Incision  of  the  Sac ;  4.  Removal  of  Sac ;  5.  Belmars 

Process  by  Plugging  and  Invagination.  Gerdy's  Method ;  Wurtzer's  Method 
Rothmund's  Method;  Prof.  D.  Hayes  Agnew's  Method;  Mosmer's  Method 
Prof.  Armsby's  Method ;  Dr.  Rigg's  Method,        .... 

Process  by  Ligature.    Prof.  John  Wood's  Method,  .... 

Process  of  Scarifying  the  Neck  and  Compression.     Alphouse  Guerin's  Process 
and  Method,  ......... 

Process  of  Acupuncture.     Bonnet's  Method, 

Process  by  Injection  of  the  Sac,  ..... 

Pancoast's  Method  and  Results,  ..... 

Remarks  on  the  Processes  of  Scarification,  Acupuncture,  and  Injection, 

Process  by  Hare-lip  Suture,     ...... 

Direct  Process,  ........ 

Process  by  Subcutaneous  Sature  with  Braid, 

Author's  Method,     ........ 

General  Remarks  on  Author's  ilethod,  .... 

Statistical  Results,  ....... 

Irreducible  Hernia.    Treatment — Palliative,  Curative, 

Inflamed  Hernia,      ........ 

Impacted  Hernia,  ....... 


2.  Exposure  of  Sac 
'  Method, 


VI 


TABLE   OF   CONTENTS. 


PAGE 

Incarcerated  Hernia,           ........  76 

Strangulated  Hernia,     .........  77 

Herniotomy.     Cutting  the  Stricture ;  Method  of  Petit ;  Guy's  Method,          .  80 
Table,  Showing  the  Causes  of  Death,              .            .            .            .            .            .84 

Hernias  of  Particular  Eegions,      .......  85 

Hernias  of  the  Hypogastric  Eegion,               .            .            .            .            .        ^  .  86 

Foniculated  Hernia,  Usually  Called  Impacted  or  Encysted  Hernia  in  the  Tunica 

Propria  Funiculse  Testis,             .......  88 

Encysted  Hernia  (Ashhurst),  Hernia  of  the  Tunica  Propria  Funiculi  Testis,      .  89 

Inguino-sub-integumental  Hernia,             ......  90 

Diagnosis  of  Eeducible  Tumors,  .  .  .  .  .  .  .91 

Diagnosis  of  Irreducible  Tumors,              ......  92 

Characters  and  Relations.    Baron  Suiten's  Method,  .  .  .  .94 

The  Eadical  Cure  of  Reduced  Inguinal  Hernia,              ....  103 

Femoral  Hernia  in  Male  and  Female,            ......  105 

Treatment  of  Femoral  Hernia,      .......  108 

Inferior  Hernia  of  the  Pelvic  Eegion,            ......  Ill 

Hernias  of  the  Mesogastric  Eegion,           ......  114 

Hernias  of  the  Epigastric  Eegion.     Intestinal  Hernia,         .            .            .            .  119 

New  Instrument  for  Eemoval  of  the  Septum  in  Artificial  Anus,         .            .  123 

Table  of  Operations  for  the  Eadical  Cure  of  Hernia  by  the  Subcutaneous  Suture,  125 


Original  Coxtbibutions  to  Operative  Sukgeky  and  New  StjKGIcax 
■  Instettments— 

Causes  of  Urinary  Calculi,       .            .            .            .            .            .            .            .  127 

Instruments  in  Use  for  the  Lateral  and  Bilateral  Operations,    .            .            .  129 

New  Instruments  for  Lithotomy  in  the  Male,            .....  147 

Report  of  Cases,       .........  148 

Strictures  of  the  Urethra,         ........  152 

Internal  Incision,     .            .            .            .            .    '        .            .            .            .  157 

Holt's  Instruments,       .........  159 

Stricture  with  Fistula  Perinei — External  Incisions,        .            .            .         ,  .  159 
A  New  Form  of  Male  Catheter  for  Stricture  of  Urethra,  and  a  New  Method  of 

Retaining  it  in  the  Bladder,        .  .  .  .  .  .  .162 

Report  of  Cases,             .........  164 

General  Remarks  on  Stricture  of  the  Urethra,     .....  170 

Incision  as  a  Means  of  Cure,                .......  179 

Enlargement  of  Prostate  Gland,     .......  181 

Case  of  Suppuration  of  Prostate  Gland,         ......  182 

A  New  Wire  Speculum  for  the  Vagina  and  Eectum,      ....  183 

Ligation  of  Varicose  Veins  with  a  Shuttle,  Double-spear-pointed,  and  Straight 

Needle, 187 

Report  of  Cases,            .            .           .           .            .•         .  .            .           .           .  188 

Dislocation  of  the  Humerus  at  the  Shoulder  Joint  (Scapulo-Humeral),           .  189 

ReiDort  of  Cases,            .........  191 

A  New  Method  for  Reduction  of  the  Phalanges  of  Hand  and  Foot,     .            .  193 
A  New  Diagnostic  Symptom  of  Dislocation  of  the  Head  of  the  Radius,  without 

Fracture  of  the  Ulna,      ........  194 

Arrow  and  Bullet  Extractor,                .......  196 

Extraction  of  an  Arrow  Head  from  the  Femur,  after  six  Years  and  Eight  Months' 

Retention,             .    »       .            .           .            .            .            .            .            .  197 

Osteo-fibroid  Tumor  of  Inferior  Axillary  Bone — Excision  of  Bone,           .            .  197 

Fibroid  Tumor  of  Thigh,                .......  199 


TABLE  OF  ILLUSTRATIONS, 


Plate  I. 
•  Plate  II. 

Plate  III, 

Fig.    5. 

Fig.    6. 

Fig.    7. 

Fig.    8. 

Fig.    9. 

Fig.  10. 

Fig.  11. 

Fig.  12. 

Fig.  13. 

Fig.  14. 

Fig.  15. 

Fig.  16. 

Fig.  17. 

Fig.  18. 

Fig.  19. 

Fig.  20. 

Fig.  21. 

Fig.  22. 

Fig.  23. 

Fig.  24. 

Fig.  25. 

Fig.  26. 

Fig.  27. 

Plate  IV. 

Plate  V. 

Plate  VI. 

Fig.  28. 

Fig.  29. 

Fig.  30. 
•     Fig.  31. 

Fig.  32. 

Fig.  33. 

Fig.  34. 

Fig.  35. 


Fig.  1  and  2.    Positions  of  Hernia  in  the  Abdominal  Eegion 
Fig.  3.    Positions  in  Skeleton, 
Fig.  4.     Position  in  Cavity  of  Abdomen, 
Hernia  in  Sac — Umbilical  Hernia, 
Hernial  Sac  laid  Open, 
Double  Sac  in  Scrotal  Hernia, 
Double  Truss,  with  Counter  Pad, 
Hirsch's  Truss,  with  Elastic  Bands,    . 
Abdominal  Supporter,        .... 
Hirseb's  Elastic  Vaginal  Truss, 
Hirscb's  Elastic  Umbilical  Truss, 
Hirsch's  Elastic  Truss,  with  Perineal  Band, 
Truss  with  Strong  Spring, 
Elastic  Bandage,  .... 

Elastic  Truss,  with  Perineal  Band, 
Single  Celluloid  Truss,  No.  2,  with  Counter-pad, 
Umbilical  Truss,  with  Steel  Spring,  covered, 
Single  Celluloid  Truss,  No.  3, 
Penfield's  Set-screw  Truss, 
German  Truss  with  Perineal  Band,     . 
Single  Celluloid  Truss,  No.  5,       . 
Double  Celluloid  Truss,  No.  9, 
Single  Celluloid  Truss,  No.  10,      . 
Wurtzer's  Instrument,  for  Radical  Cure, 
Dr.  Agnew's  Instrument,         "        .  « 
Prof.  Beckwith's  Method,        "  " 

Fig.  1,  2,  3.    Author's  Method,  for  Eadical  Cure, 
Author's  Method,  " 

Author's  Method,  "  " 

Probe  Pointed  Bistoury,  for  Cutting  Stricture, 
Cutting  the  Stricture  in  Herniotomy, 
Abdominal  Divisions, 

Double  Inguinal  Hernia,  Direct  and  Oblique,    . 
Scrotal  Hernia,  showing  the  Usual  Pvelations  of  the  Sac, 
Infantile  Scrotal  Hernia,  .... 

Inguino-sub-integumental  Hernia, 
French  Truss  for  the  Eadical  Cure  of  Inguinal  Hernia, 

vii 


PAGE 

13 


VIU 


TABLE   OF   ILLUSTRATIONS. 


Fig.  36. 
Fig.  37. 
Fig.  38. 
Fig.  39. 
Fig.  40. 
Fig.  41. 
Fig.  42. 
Fig.  43. 
Fig.  44. 
Fig.  45. 


Fig.  46. 


Fig.  47. 
Fig.  48. 
Fig.  49. 
Fig.  50. 
Fig.  51. 
Fig.  52. 
Fig.  53. 
Fig.  54. 
Fig.  55. 
Fig.  56. 
Fig.  57. 
Fig.  58. 
Fig.  59. 
Fig.  60. 
Fig.  61. 
Fig.  62. 

Fig.  63. 

Fig.  64. 

Fig.  65. 

Fig.  66. 

Fig.  67. 

Fig.  68. 

Fig.  69. 

Fig.  70. 

Fig.  71. 

Fig.  72. 

Fig.  73. 


Sherman's  Truss  for  the  Radical  Cure  of  Inguinal  Hernia, 
Truss  for  Vaginal  Hernia,  .... 

Elastic  Bands  for  Thigh,  Elastic  Stockings,  etc.. 

Truss  for  Ventral  Hernia  and  Abdominal  Supporter,     . 

Rombert's  Suture  for  Intestinal  Wounds, 

Gely's  Suture  for  Intestinal  Wounds, 

Instrument  for  Removal  of  Septum  in  Artificial  Anus, 

Author's  Staff  and  Urethrotome  for  Lithotomy, 

Author's  Gorget  for  Lithotomy,  .... 

Xo.  1.    Westmoreland's  Urethrotome  for  Stricture, 

No.  3.    Syme's  Urethral  Staff,  .... 

No.  4.     Grooved  Director  for  Stricture, 

No.  5.     Tenotomy  Knife  for  Stricture, 

No.  1.    Retention  Catheter,  old  style, 

Nos.  2  and  3.    Gouley's  Filiform  Catheter,    . 

No.  5.    Hook  for  Stricture,  .... 

Holt's  Improved  Dilators,  Nos.  1,  2,  3, 

Gouley's  Bistoury  for  Extei-nal  Incision, 

Gouley's  Form  of  Urethrotomes,         .... 

Author's  Retention  Catheter,        .... 

French  Scale  of  Catheters,       ..... 

Dr.  Otis'  Urethra-meter,    ..... 

Dr.  Gouley's  Urethrotome,       ..... 

Holt's  Original  Instruments,         .... 

Canulated  Sound,  for  Cauteri2dng  Urethra  and  Prostrate  Gland, 

Bulbous-pointed  Flexible  Catheter, 

Vertebrate  Silver  Catheter,      ..... 

Gouley's  Ligating  Instrument,      .... 

Sound,  with  Guide,        ...... 

Exploring  Catheter  and  Sound,     .... 

Double  Canulated  Catheter,     ..... 

Wire  Speculum,      ...... 

Improved  Wire  Speculum,       ..... 

Wire  Speculum,  Sim's  Patent,       .... 

Ligating  Varicose  Veins,  ..... 

Natural  Position  of  Arm  Bones  without  Fracture, 
Humerus  Dislocated,     ...... 

Reduction  of  Dislocated  Shoulder, 

Mode  of  Reducing  Phalanx,    .  .  .       '     . 

Second  Phalanx  Dislocated,  .... 

Head  of  Radius  in  Clinoid  Fossa  in  its  dislocation, 
Indian  Arrow  Extractor,    ..... 

Jacob  Young,  Osteo-fibroid,  Tumor, 


PAGE 

103 
113 
115 
116 
122 
122 
123 
147 
147 


156 


157 
159 
16o 
161 
163 
165 
171 
172 
180 
181 
182 
182 
182 
183 
183 
183 
185 
186 
187 
187 
191 
191 
19*2 
193 
194 
194 
196 
196 


HERNIA-RUPTURE. 


The  word  Hernia  comes  from  spvo^,  and  means  a  protrusion — a 
brancli,  and  has  been  used  by  writers  on  Pathology  in  a  general 
sense,  to  mean  only  protrusion  of  the  contents  of  a  cavity  through 
its  walls :  as,  Hernia  Cerebri — the  protrusion  of  the  brain  through 
the  dura  mater  and  cranial  wall;  Hernia  Pulmonalis — the  pro- 
trusion of  the  lung  through  the  walls  of  the  chest ;  Heenia  Abdomi- 
NALis — the  protrusion  of  any  of  the  viscera  in  the  abdominal  cavity 
through  any  of  its  natural  openings^  or  through  a  rupture  in  its 
solid  superficial  walls;  then  we  have  Hernia  Vesicis — hernia  of  the 
bladder — where  the  internal  coat  is  pushed  through  the  muscular 
coat,  and  pressed  on  the  perineum  or  other  surroundings  of  the 
bladder ;  Hernia  Sclerotici — ^protrusion  of  the  contents  of  the  ball 
through  the  sclerotic  coat  of  the  eye.  Some  apply  the  use  of  this 
word  to  aneurisms  and  the  accumulation  of  fluids  in  the  knee,  mak- 
ing protrusions  through  the  serous  sac ;  also  to  hemorrhages  into 
cavities  protruding  and  pressing  through  its  walls. 

Hernial  protrusions  may  be  covered  with  skin  and  superficial: 
fascia,  also  by  the  serous  tissue ;  or  they  may  protrude  through  a 
clean  cut,  or  a  gunshot  wound,  without  any  covering.  Most  usu- 
ally they  have  the  serous  coat,  the  superficial  fascia,  and  the  skin 
for  their  coverings,  with  other  layers  peculiar  to  special  Hernias 
(I  use  hernias  here  in  the  plural,  instead  of  ruptures,  as  rupture 
does  not  mean  hernia,  and  is  not  a  good  synonym). 

Hernia  Abdominalis — Abdominal  Hernia.  This  is  the  genus 
or  class  we  shall  treat  of,  as  the  other  classes  do  not  necessarily 
come  under  observation  to  illustrate  this  class ;  they  have  but  a 
few  symptoms  in  common,  and  they  are  comparatively  rare  and 
not  often  met  with ;  besides,  they  are  usually  produced  by  incised, 
punctured,  or  gunshot  wounds,  and  rarely  by  pressure  from  within, . 
or  compression  of  the  external  walls  on  their  contents. 

Abdominal  Hernia  is  divided  into  many  varieties  and  sub-vari- 
eties, to   more    particularly  define  its   position,  its   contents^  its 
mobility,  its  stage  and  line  of  progress,  time  of  protrusion,  whether- 
before  or  after  birth,  cau^esy  whether  traumatic  or  idiopathic. 
2  9 


10  HERNIA. 

General  Symptoms. — There  is  always  a  tumor  in  the  region 
where  the  Hernia  comes  out,  of  variable  size,  from  that  of  a 
knuckle  to  that  of  a  man's  head.  This  tumor  is  usually  reducible 
— can  be  pushed  back  into  the  cavity  from  which  it  came — but  will 
return  when  left  to  the  muscular  action  of  the  parts,  except  when 
it  becomes  strangulated  or  impacted,  that  is,  incarcerated,  as  we 
will  show  when  we  come  to  speak  of  strangulated  hernia.  When 
strangulated  it  cannot  be  easily  reduced ;  or  it  may  be  irreducible 
without  strangulation,  by  adhesion  to  the  walls  of  the  sac.  Its  con- 
tents vary.  When  the  intestines  are  protruded,  the  tumor  is  soft 
and  gaseous,  and  will  sometimes  produce  a  gurghng  or  crackling 
sound.  When  the  tumor  contains  omentum,  it  is  more  sohd  and 
of  a  doughy  feeling,  and  not  so  easily  reduced.  When  the  spleen, 
liver,  or  kidneys  are  protruded,  it  is  nearly  solid,  at  least  quite  firm 
in  comparison  with  the  other  varieties. 

General  Causes. — These  tumors  are  produced  in  some  instances 
suddenly,  by  falls,  by  kicks  feom  horses,  cows,  and  other 
ANIMALS,  by  'punches  from  horns  of  cattle,  by  the  handles  of 
ploughs,  and  spikes  of  machinery,  by  'muscular  pressure,  as  by 
jumping,  falling,  and  aRADUALLT,  almost  imperceptibly,  by 
riding,  coughing,  crying,  laughing,  defecating,  throes  of  parturi- 
tion, cramps  and  strainings  in  urinating  in  strictures  of  the  urethra 
and  stone  in  the  bladder,  in  playing  on  wind  instruments,  from 
dilatations  by  worms,  by  ovarian  tumors,  pregnancy,  and  tight 
lacing. 

Special  Symptoms. — When  the  protrusion  is  produced  sudden- 
ly, there  is  great  pain  and  soreness  in  the  tumor,  heat,  redness, 
swelling,  and  great  tension.  When  these  s}niLptom5  are  not  soon 
relieved,  the  contents  become  strangulated,  and  mortification  takes 
place  rapidly,  attended  with  hiccough,  stercoraceous  vomiting,  cold 
clammy  sweats,  with  quick  and  feeble  pulse,  and  lastly,  shock  and 
death.  The  progress  of  these  symptoms  depends  upon  the  tight- 
ness of  the  stricture.  If  the  strangulation  is  complete,  so  no  blood 
can  flow  into  or  out  of  the  tumor,  sphacelation  will  take  place  in 
twenty-four  hours,  and  some  say  in  six.  But,  if  not  tight  enough 
to  prevent  the  passage  of  the  faeces,  it  may  not  produce  impaction, 
and  the  bowels  may  be  moved,  and  there  wiU.  remain  an  irreduci- 
ble hernia,  that  may  stand  for  years  and  not  produce  serious  re- 
sults, but  the  patient's  life  is  in  danger  at  all  times  from  impaction 
and  strangulation.     Hernia  may  form  almost  imperceptibly  to  a 


PEOPOETION   OF    HERNIAS. 


11 


patient,  producing  no  appreciable  pain  and  but  little  soreness.  This 
soreness  may  be  occasionally  felt  on  riding  a  trotting  borse,  climb- 
ing a  tree,  or  lifting  a  weight,  and  pass  off  until  some  other  mus- 
cular pressui'e  may  force  it  out.  In  some  situations,  as  in  the 
inguinal  ring,  or  the  femoral  ring,  a  small  knuckle  of  omentum 
or  intestine  may  be  pressed  partly  out,  and  become  strangulated  in 
its  course  without  producing  a  perceptible  tumor,  and  may  often  be 
taken  for  an  inflamed  gland  or  an  incipient  bubo.  These  cases 
must  be  carefully  watched,  and  a  close  and  careful  examination 
made,  for  while  an  inflamed  bubo  is  comparatively  of  little  import- 
ance, these  cases  are  extremely  dangerous,  and  soon  result  in  all 
the  painful  phenomena  just  described. 

PEOPORTION   OF   HERNIAS    TO    NUMBER   OF    INHABITANTS. 

Table  showing  the  number  of  exemptions  from  the  various  forms  of  Hernia,  compiled 
from  the  report  of  Provost  Marshal  J.  B.  Fry,  from  the  examinations  of  605,045 
drafted  men  during  the  late  war : — 


VARIETIES. 

No.  Exempted. 

Ratio  per  1000. 

Hernia 

Hernia  Ventral 

Hernia  Umbilical 

Hernia  Inguinal 

Hernia  Femoral         .        .        .        .        . 

2,705 

310 

123 

13,994 

500 

4.47 

.51 

.20 

23.13 

.83 

Total 

17,632 

29.14 

Table  showing  the  proportion  of  deaths  from  Hernia  to  deaths  from  all  other  causes 
reported  in  the  U.  S.  Census  for  1850,  1860,  and  1870  :— 


Census. 

"Whole  No.  of  deaths. 

Deaths  from  Hernia. 

Ratio  per  Thousand. 

1850 
1860 
1870 

271,890 
394,153 
492,263 

241 
360 
638 

1.132J 

1.0941 

.771i 

Total 

1,158,306 

1239 

.999  -f- 

The  number  of  deaths  from  Hernia,  to  the  entire  number  of 
deaths  in  the  United  States,  is  one  in  771|,  or,  in  the  entire  popu- 
lation, one  in  60,432J.  According  to  the  census  of  1870,  entire 
population,  38,555,983;  entire  deaths,  402,263.  Males,  465; 
females,  173 ;  total,  638.  Katio  per  1000,  1.65.  The  deaths 
from  hernia  to  the  entire  deaths  at  the  same  period,  were,  male 
and  female,  638 ;  total,  302,263.  Eatio,  to  1000,  1.585.  The 
census  also  shows  that  the  greatest  number  of  males  die  in  the 
months  of  January  (42),  April  (51),  June  (17),  July  (27),  Septem- 
ber (17),  October  (37),  November  (42),  December  (37).  Females— 
Highest,  January  (33),  June  (17),  July  (18) ;  lowest,  January  (11), 
February  (8),  May  (12),  December  (11). 


12  HERNIA. 

These  data  show,  to  one  familiar  with  the  industry  of  the  United 
States,  that  in  the  months  for  rolHng  logs  and  clearing  up  of  lands 
we  have  the  greatest  number  of  deaths  in  males,  and  when  cultivating 
and  gathering  of  crops,  the  least ;  while  in  the  female,  during  the 
winter  months,  when  she  is  confined  to  the  house,  she  is  less  liable ; 
and  in  the  summer  and  fall  months,  when  she  assists  in  gathering 
the  crops,  she  is  most  liable ;  but  it  will  be  seen  that,  as  we  before 
stated,  the  ratio  is  about  1  in  2687,  or  in  the  proportion  of  465  to 
173,  being  000.75  per  one  thousand  of  all  female  deaths  in  1870. 
This  ratio  of  mortality  would  give  6380  deaths  from  hernia  every 
ten  years.  This  would  reduce  the  ratio  of  a  maris  life  loho  is 
laboring  under  hernia  to  thirty-six  years,  from  the  average  of  forty- 
two,  in  the  United  States. 

GRAVITY   OF   THE   DISEASE. 

Hernia,  whether  considered  in  its  mortality  or  the  results  of  its 
treatment,  may  be  pronounced  one  of  the  gravest  of  lesions  the 
surgeon  has  to  contend  with,  requiring  anatomical  knowledge  to 
diagnose,  and  great  skill  and  operative  tact  to  treat  its  various 
complications. 

CLASSIFICATION   OF   ABDOMINAL  HERNIA. 

Time  of  Rupture — Whether  before  or  after  birth. 

1.  Congenital — Occurring  in  foetus  before  birth. 

2.  Non-Congenital — Occurring  after  birth. 

ITS   STAGE   AND    LINE    OF    PROGRESS. 

1.  Incomplete — Where  the  tumor  is  lodged  in  the  walls  and  has 
not  made  its  exit. 

2.  Complete — Where  the  tumor  has  passed  through  the  walls  of 
the  abdomen. 

DIRECTION   OF   THE   PROTRUSION. 

1.  Oblique — Where  the  hernia  passes  obliquely  through  the  walls 
of  the  abdominal  cavity,  as  oblique  inguinal  hernia. 

2.  Direct — Where  it  passes  directly  out  at  one  ring  or  through 
a  straight  rupture,  as  direct  inguinal  hernia. 

POSITIONS   IN   THE   ABDOMINAL   REGION. 

These  are  made  plain  by  the  accompanying  diagrams  (Plate  i, 
Figures  1  and  2). 


POSITIONS  IN  THE   ABDOMINAL  EEGION. 


18 


Pl^  I— Figs,  1  AND  2.— 1.  Epigastric  Region.  2.  Lumbar  Region.  3.  CTmbilical 
Region.  .4.  Feinoral  Region.  5.  Poupart's  Ligament.  6.  Sclrpa's  Triangle  A 
Epigastric  Hernia^  B  Hypochondriacal  Hernia.  C.  LumbralSernia  D.  ilrn 
^'il^.^^l^^^'o-  E-  Ventral  Hernia.  F.  Inguinal  Hernia.  G.  Direct  Inguina 
Hernia.    H.  Crural  Hernia.    I.  Femoral  Hernia.  cv.l  xxiguind, 


14  HEENIA. 

1st.  Epigastric — "Where  the  rupture  appears  in  the  epigastric 
region. 

2d.  Hypochondriacal — Where  it  appears  in  the  left  or  right  side 
upper  region,  or  hypochondrium.     (Plate  ii,  C.  D.) 

3d.    Umbilical — Where  it  appears  at  the  umbilicus. 

4th.  LuTTbbral — Where  it  appears  in  the  right  or  left  lumbar 
region. 

5th.  Ventral — Where  it  appears  in  the  median  line  above  or 
below  the  umbilicus,  or  between  the  umbilicus  and  the  linia  semi- 
circularis  above  or  below,  right  or  left, 

6th.  Inguinal — Where  it  appears  in  the  right  or  left  inguinal 
region. 

7th.  Crural — Where  it  appears  at  the  left  or  right  crural  region, 
in  the  femoral  or  Scarpa's  triangle,  at  its  upper  portion. 

8th.  Femoral — Where  it  appears  below  the  falciform  process,  in 
the  femoral  triangle. 

9th.  Phrenic  or  Diaphragmatic — Where  it  passes  through  the 
diaphragm,  whether  through  the  natural  openings,  as  the  ascending 
vena  cava,  aorta  or  oesophagus,  or  through  an  opening  made  by  a 
wound  through  its  walls.     (Plate  ii,  A.  B.) 

10th.  Ischiatic — Where  it  passes  out  through  the  ischiatic  open- 
ing, along  with  the  ischiatic  nerve,  artery  and  vein.  (Plate  ii,  E.  F.) 

11th.  Obturator — Where  it  comes  through  the  obturator  foramen, 
with  the  obturator  artery  and  vein.     (Plate  ii,  G.  H.) 

12th.  Vaginal — Where  it  passes  through  the  walls  into  the 
vagina. 

13th.  Perineal — Where  it  passes  between  the  vagina  and  rectum 
out  on  the  perineum. 

14th.  Rectal — Where  it  passes  through  the  walls  of  the  rectum 
and  rests  in  its  cavity,  forming  a  heterocele. 

15th,  Labial — Where  it  passes  out  under  the  pudendum  in  any 
part. 

16th.  Scrotal — Where  it  passes  into  the  scrotum  from  the  in- 
guinal rings. 

17th.  Enteronal — Where  it  passes  through  a  loop  of  intestine 
produced  by  adhesion  internally,  and  simulates  intussusception,  or 
where  it  forms  a  sac  in  the  mesentery.     (Plate  iii,  G.) 

18th.  Tiivaginal — Where  one  portion  of  an  intestine  passes  into 
another,  invaginating  it,  and  thereby  obstructing  the  alvine  evacua- 
tions. 


DIFFEEENT   HERNIAS. 


15 


Plate  IT— Fig.  3.— 1  and  2.  Diaphragmatic  Hernia,  A.  and  B.  Neck  of  Diaphraem- 
atic  Hernia.  C.  and  D.  Necli  of  Lumbral  Hernia.  E.  and  F.  Openine  for  Ischi- 
atic  Hernia.    G.  and  H.  Opening  for  Obturator  Hernia. 


16  HERNIA. 

IQth.  Encysted — Hernia  Infantilis — Where  the  hernia  forms  in 
the  inguinal  process  and  comes  up  to  the  external  ring. 

20th.  Ligamentatic — Ovarian  hernia,  where  it  forms  in  the  canal 
of  Nuck-ligamentous  process. 

21st.  Diverticular — "Where  the  mucous  and  muscular  coats  of  the 
intestines  are  ruptured,  and  the  contents  of  the  bowel  pass  into 
the  sac.     (Plate  iii,  E.) 

CONTENTS   OF  A   HERNIAL   SAC. 

1st.  Enterocele — Where  the  contents  of  the  sac  are  only  intes- 
tine. 

2d.  Omentoeele — Where  the  contents  are  omentum. 

3d.  Angeo-Mesenteriocele — Where  a  mesenteric  gland  and  a  por- 
tion of  the  mesentery  is  in  the  sac. 

4th.   Mesocolonocele — Where  the  meso-colon  is  secured  in  the  sac. 

6th.  Viscerocele — Where  portions  of  the  liver,  spleen  or  kidney  are 
included  in  the  tumor. 

6th.  Gastrocele — Where  the  stomach  is  in  the  sac. 

7th.    Veserocele — Where  the  bladder  is  in  the  sac. 

8th.  Entero-epiplocele — Where  intestine  and  omentum  are  both 
found  in  the  sac. 

9th.  Ovariocele — Where  an  ovary  is  found  in  the  sac. 

MOBILITY   OF   TUMOR   IN   CASES   OF   HERNIA. 

1st.  Reducible — Where  the  contents  of  the  tumor  may  be  easily 
reduced. 

2d.  Irreducible — Where  the  contents  cannot  be  reduced,  but  are 
retained  by  adhesions,  with  or  without  strangulations,  or  from  im- 
paction. 

3d.  Strangulated — Where  the  contents  contained  in  the  sac  can- 
not be  reduced,  and  are  compressed  in  some  portions,  so  as  to  cut  off 
the  circulation  of  the  blood  and  prevent  the  alvine  flow. 

4th.  Impacted — Where  the  sac  is  filled  with  fecal  matter,  so  it 
cannot  be  returned. 

CAUSES   PRODUCING   HERNIA. 

1st.   Traumatic — Where  the  hernia  is  known  to  be  produced  by 
a  wound  or  burn. 
2d.  Idiopathic — Where  hernia  is  produced  by  the  contraction  of 


DIFFERENT  HEENIAS. 


17 


PliATE  III— Fig.  4.— a.  Chain  holding  open  the  Chest,  C.  and  D.  Intestine  in  Dia- 
phragmatic Hernia.  E.  Appendiformical  Hernia.  F.  Intussusception.  G.  In- 
testinal Hernia.    H.  Artificial  Anus.    I.  Caecum. 


18 


HERNIA. 


the  muscles,  or  weakness  at  the  natural  openings,  or  where  it  fol- 
lows the  testicle  in  its  natural  descent. 


DYCOTAL   TABLE  OF   HERNIA. 

All  hernias  are  either  congenital  or  non-congenital.  All  con- 
genital hernias  are  idiopathic.  All  non-congenital  hernias  are 
either  traumatic  or  idiopathic.  All  idiopathic  or  traumatic  her- 
nias may  be  reducible.  All  reducible  hernias  may  become  irre- 
ducible by  adhesions  without  strangulation  or  impaction,  and  all 
irreducible  hernias  may  become  strangulated  or  impacted. 

All  strangulated  or  impacted  hernias  may  be  found  in  the  fol- 
lowing places,  and  take  the  following  names,  in  about  the  order  we 
have  stated  them — the  most  common  being  named  first,  and 
the  most  unusual  last.  We  give  the  following  table,  to  be  filled  by 
statistics.     We  give  only  our  own  observations. 


In  the  Male. 
Inguinal, 
Scrotal, 
Crural, 
Umbilical, 
Ventral, 
Epigastric, 
Lumbral, 
Femoral, 
Diaphragmatic, 
Ischiatic, 
Obturatic, 
Enteronal, 
Spermatic, 
Infundibulatic, 
Diverticulatic. 


In  the  Female. 
Umbilical, 
Ventral, 
Crural, 
Inguinal, 
Femoral, 
Infundibulatic, 
Diverticulatic, 
Labial, 
Vaginal, 
Epigastric, 
Rectal, 
Ischiatic, 
Obturatic, 
Ovariatic, 
Intusceptic, 
Ligmentatic. 


SIZES   OF   HERNIAS. 


All  hernias  vary  in  size,  from  a  pigeon's  egg  to  that  of  a  man's 
head.  We  class  hernias  in  the  following  table  according  to  their 
size,  giving  the  largest  varieties  first,  in  the  order  in  which  they 
are  usually  supposed  to  be  found,  in  both  male  and  female : — 


SIZE   OF   HERNIAS. 


19 


Male. 
Scrotal, 

Ventral, 

Umbilical, 

Epigastric, 

Lumbral, 

Hypochondric, 

Diaphragmatic, 

Kectal, 

Femoral,. 

Ischiatic, 

Obturatic, 

Enterocelic, 

Intusceptic, 

Spermatic, 

Freniculatic. 


Female. 
Umbilical, 
Ventral, 
Epigastric, 
Lumbral, 
Hypochondric, 
Diaphragmatic, 
Rectal, 
Vaginal, 
Femoral, 
Labial, 
Ischiatic, 
Obturatic, 
Enterocelic, 
Intusceptic, 
Infundibulatic, 
Ligamentatic. 


All  Heenias  have  either  Sacs  with  other  Coverings,  or 

THEY  ARE  WITHOUT  SaCS  OR  COVERINGS. 

This  applies  alike  to  male  and  female,  whether  with  or  without 
coverings.     See  Figures  5  and  6.     The  tumor  may  be  composed  of 


Fig.  5. 


A.  Hernia  in  Sac.    CO.  Abdominal  Walls.    D.  Intestine.    E.  and  F.  Folds  of  Intes- 
tine in  Sac. 


the  following  anatomical  parts,  or  a  combination  of  them,  in  the 


20 


b.  Sac  laid  open.    c.  Abdominal  Wall.    d.  Omentum  in  Sac  of  Scrotum. 

order  in  whicli  we  give  them,  the  most  common  being  first,  and  the 
least  common  last : — 

Enterocele,  epiplocele  (omentocele),  angeo-mesenterocele  (gland 
and  mesentery),  meso-colonicele  (colon  and  meso-colon),  viscerocele 
(liver,  spleen,  kidney,  uterus  or  ovary),  gastrocele  (stomach),  vesi- 
cele  (bladder),  csecocele  (csecum). 

COMPOUND   CONTENTS. 

These  may  be  any  two  of  the  above  or  even  more,  as  in  some 
cases  of  umbilical  and  ventral  hernias  we  find  stomach,  liver,  small 
intestines,  and  omentum.  Again  we  find  the  uterus,  bladder,  liga- 
ments, ovaries,  intestines  and  omentum.  Where  only  two  anatomi- 
cal parts  are  included,  they  are  named  as  follows : — Entero-epiplo- 
cele  (omentum  and  intestine) ;  entero-vesicocele  (bladder  and 
intestine);  entero-gastrocele  (stomach  and  intestine);  entero-spleno- 
cele  (spleen  and  intestine) ;  entero-renocele  (kidney  and  intestine) ; 
epiplo-splenocele  (spleen  and  omentum);  epiplo-gastrocele  (stomach 
and  omentum);  epiplo-renocele  (kidney  and  omentum);  epiplo- 
uterocele  (uterus  and  omentum);  epiplo-vesicocele  (bladder  and 
omentum). 


GENERAL   PREDISPOSINa  CAUSES.  21 

This  list  comprises  all  the  usual  varieties.  The  part  most  usually- 
protruded  should  be  put  first  in  giving  the  contents. 

GENERAL   PREDISPOSING  CAUSES — INCITING   CAUSES   AND   EXCITING 

CAUSES. 

Many  conditions  predispose  to  hernia,  such  as  sex,  age,  inherit- 
ance and  conditioyis  in  life,  which  more  or  less  predispose  the 
patient  to  the  inciting  causes,  as  relaxation  of  the  muscles,  relaxa- 
tion of  the  rings,  general  debility  and  olSesity. 

The  local  predisposing  causes  are  wounds,  weakening  the  walls, 
hums,  abscesses,  ovarian  tumors,  ascites,  punctures  of  surgical  in- 
■  struments,  as  paracentesis  abdominis,  gastrotomy ;  the  removal  of 
tumors  from  the  external  wall. 

A  frequent  predisposing  cause  in  the  male  is  the  patulency  of 
the  inguinal  process,  especially  of  its  ventral  orifice,  usually  called 
vaginal,  which  name  I  think  is  objectionable,  as  it  leads  the  student 
to  think  of  the  vagina ;  throughout  this  treatise  we  will  call  it 
inguinal  process  in  the  male,  and  when  it  is  applied  to  the  female, 
infundibulum  process,  and  ligaraental  process,  after  the  passage 
down  of  the  testicle.  Marriage  is  a  powerful  predisposing  cause  in 
the  male ;  the  proportion  of  cases  in  married  men  is  as  2  to  1. 

We  well  know  that  the  testicle  is  found  in  the  lumbar  region, 
and  behind  the  peritoneum;  it  gradually  makes  its  way  down, 
pressing  before  it  a  fold  of  the  peritoneum,  forming  the  ventral 
orifice ;  pushing  its  way  further  down,  it  reaches  the  external  orifice, 
forming  the  inguinal  process,  or  tunica  propria  testis,  and  lies  above 
the  cord,  and  continuing  on  down,  it  still  carries  a  fold  of  the  peri- 
toneum, and  about  where  the  epidydimitis  commences,  it  folds  over 
it  and  the  testicle,  and  forms  the  tunica  albuginia  propria  testis. 
The  inguinal  process,  or  tunica  propria  funiculi,  should  be  closed  at 
birth,  from  its  ventral  to  its  testicular  orifices,  but  this  is  often  not 
the  case,  and  greatly  predisposes  to  oblique  inguinal  and  scrotal 
hernias,  and  is  the  principal  cause  of  congenital  hernia  of  this 
region.  This  process  is  sometimes  closed  at  both  orifices,  and 
patulous  between,  filling  with  serum,  forming  a  complication  that 
may  confuse  the  operator  for  direct  inguinal  hernias  in  this  region, 
or  it  may  be  open  at  either  orifice,  and  closed  in  its  course,  each 
producing  a  weakening  of  the  part,  and  the  internal  orifice  par- 
ticularly predisposing  to  incomplete  hernia;  and  those  of  gradual 
formation. 


22 


HEENIA. 


Fig.  7. 


Relaxation  of  the,  mesentery,  redundance  of  omentum  and  re- 
laxation of  the  mesocolons  greatly  predispose  to  hernia,  especially 

of  the  larger  class,  as  umbilical,  ven- 
tral and  scrotal,  and  in  fact,  "without 
this  relaxation  and  dragging  down  of 
these  parts  the  large  hernia  could  not 
occur.     See  Figure  7. 

Inflammation  and  cicatrization  of 
the  peritoneum,  causing  it  to  give  way 
on  pressure,  is  also  an  inciting  or  pre- 
disposing cause.  Relaxation  of  its 
fibres  by  constant  straining  in  cough- 
ing, laughing,  crying,  defecating, 
paiyifid  micturition  from  stone  and 
stricture,  is  a  general  inciting  cause 
in  all  idiopathic  hernias. 

Before  passing  to  the  anatomy  or 

structure  of  hernia,  it  might  be  well 

for  us  to  examine  more  closely  and 

see  what  proportional  influence  age, 

sex,  condition  and  inheritance  have 

over  the  formation  of  hernias. 

The  London  Teuss  Company  has  given  us  the  most  extensive 

and  reliable  table  on  age  and  sex  we  have,  and  we  give  it  in  full 

below.     Out  of  77,997  cases  we  have  the  following  results : — 


Double  Sac  in  Scrotal  Hernia. 


YEAES. 

CASES. 

YEARS. 

CASES. 

From    1  to  10    . 

7,229 

From  50  to    60  . 

14,169 

"      10  "  20 

4,551 

"      60  "    70      . 

9,761 

"      20  "  30    . 

8,715 

"      70  "    80  . 

3,866 

"      30  "  40 

13,614 

"      80  "     90      . 

442 

"      40  "  50    . 

15,627 

"      90  "  100  . 

23 

There  are  more  cases  of  hernia  between  one  to  ten  than  any 
other  age,  but  relative  to  population,  it  is  greater  after  thirty-five 
years,  and  gradually  increases  as  age  advances,  from  the  continua- 
tion of  the  general  predisposing  causes,  local  inciting  causes  and 
the  immediate  or  exciting  causes  continuing  the  same  through  life, 
hence  longevity  is  a  permanent  predisposing  cause  of  hernia.  Men 
suffer  much  more  than  women  from  hernia,  believed  to  be  about 
four  and  a  half  to  one,  the  deaths,  as  we  have  shown,  being  about 
2.675  per  cent,  greater ;  but  this  ratio  of  deaths  would  be  much 


ANATOMY   OB,   STRUCTURE   OF   HERNIA.  23 

greater  if  females  were  as  liable  to  strangulation  as  men;  but  they 
are  not,  in  the  proportion  of  1  to  1.5  in  males,  owing  probably  to 
their  occupation,  but  greatly  due  to  the  diflPerence  between  the  for- 
mation of  the  spermatic  cord  and  the  coming  down  of  the  testicle, 
and  round  ligaments  and  the  ovaries. 

The  London  Truss  Company  gives  us  the  following  data :  out  of 
83,584  cases  relieved,  67,798  were  males,  and  15,786  females, 
making  about  the  proportion  of  4|-  to  1,  as  before  given. 

Men  are  predisposed  and  more  liable  to  different  kinds  of  hernias, 
as  inguinal;  women  to  femoral,  ventral,  umbilical,  and  all  the 
pelvic  varieties.  Men  alone  are  liable  to  scrotal ;  women  alone  to 
vaginal,  labial  and  pudendal. 

Occupation  has  much  to  do  with  the  producing  of  hernias,  as 
we  have  foreshadowed  in  giving  the  months  in  which  the  greatest 
number  of  deaths  occur.  Any  occupation  requiring  muscular 
straining,  especially  of  a  continuous  character,  greatly  promotes 
hernias,  by  dilating  the  rings,  separating  the  relaxed  fibres.  Those 
that  are  liable  to  produce  burns  of  the  abdomen,  cuts  or  contu- 
sions, as  we  have  before  given,  as  sailors,  soldiers,  engineers,  car- 
penters, etc. 

Inheritance  has  a  serious  influence  on  the  production  of  hernia, 
as  well  as  other  malformations,  for  wherever  it  is  congenital  there 
is  a  malformation  that  does  not  prevent  the  protrusion.  It  is  not 
unusual  to  see  whole  families  affected  with  hernia,  father  and  all 
his  sons ;   a  majority  is  a  common  thing. 

ANATOMY   OR   STRUCTURE    OF    HERNIA. 

All  hernias,  except  those  we  have  mentioned  before,  to  wit,  those 
produced  by  incised  wounds,  and  hernia  of  the  bladder  and  csecum, 
which  lie  mostly  out  of  the  peritoneum,  have  no  peritoneal 
covering  on  their  lower  and  outer  sides,  hence  they  easily  become 
strangulated,  or  rather  irreducible,  by  adhesion  of  the  adjoining 
parts. 

The  hernial  sac  is  formed  out  of  the  peritoneum  by  its  gradual 
distention,  as  the  blowing  up  of  a  bladder.  When  the  sac  is  com- 
pletely full,  the  peritoneum  lining  it  is  put  on  the  stretch  and  is 
fally  distended,  but  when  the  hernia  is  reduced,  the  peritoneal  sac 
contracts  on  itself  to  a  certain  extent,  hke  an  inflated  bladder,  but 
fills  again  as  the  contents  are  pressed  into  it.  The  sac  has  always 
a  mouth,  neck,  body  a,n3.  fundus.     See  Figure  7,  page  22. 


24  HERNIA. 

The  mouth,  is  the  internal  orifice ;  the  neck  is  the  part  constricted 
by  the  walls  of  the  opening;  the  body  is  the  expanded  portion  lying 
under  the  skin  and  fascia;  the  fundus  is  its  lower  portion  rounded 
on  itself. 

There  may  be  two  or  more  of  these  sacs  on  the  same  side,  some- 
times leading  into  one  neck;  some  may  be  quite  large  and  others 
small.  The  sac  is  always  the  size  of  the  tumor,  being  its  internal 
cover,  and  consequently,  from  a  "pigeon's  egg  to  an  adult  man's 
head."  Sacs  that  are  in  the  line  of  descent  of  the  testicle  are 
called,  by  some,  congenital  sacs,  and  those  forming  gradually  and 
out  of  the  normal  canals,  non-congenital. 

Acquired  Sacs. — These  sacs,  of  course,  contain  all  the  parts  we 
have  described  in  our  dycotinous  table,  and  need  not  be  repeated 
here,  but  in  addition  to  intestine,  omentum,  etc.,  they  have  float- 
ing bodies,  apparently  from  the  omentum,  but  more  probably  the  re- 
sult of  former  acute  inflammations,  and  are  membranous,  like  croupal 
exudations.  They  have  always  more  or  less  serum,  and  sometimes 
the  serum  is  in  such  great  quantity  as  to  make  up  the  tension,  and 
increase  the  size  of  the  sac  to  double  its  former  dimension.  The 
thickening  of  the  sac  also  varies  from  that  of  an  almost  transpa- 
rent membrane  to  a  thick  rough  coat,  corrugated  and  indented. 

The  shape  of  the  sac  varies  according  to  the  place  of  its  protru- 
sion, and  is  small  or  large,  according  to  the  room  it  has  to  expand 
in,  as  we  have  seen  in  umbilical,  ventral,  and  scrotal  hernias,  and 
as  small  as  a  pigeon's  egg,  where  it  passes  under  the  ilio-pubic 
ligament,  forming  crural  hernia  or  an  ovarian  and  csecal.  In 
incomplete  hernia  the  sac  has  a  large  mouth  and  conical  body  and 
fundus.  In  the  inguinal  variety  it  is  often  hour-glass  shaped; 
but  when  well  formed  it  is  nearly  exact  in  character  to  Figure  7, 
page  22. 

The  sac  rarely  ever  has  any  muscular  fibres.  In  scrotal  hernia  it 
is  not  uncommon  for  the  lower  portion  of  the  tunica  propria  testis 
to  be  filled  with  serum,  forming  a  true  hydrocele,  while  the  hernia 
lies  protruded  above.  This  serum  may  be  indirectly  connected 
with  the  hernial  sac,  or  be  entirely  shut  off  from  it;  these  cavities 
are  no  doubt  formed  out  of  an  old  sac,  from  which  the  hernia  has 
been  reduced,  and  pressure  with  a  truss  or  some  other  cause  has 
caused  adhesive  inflammation  and  closed  up  the  neck,  or  it  may  have 
closed  spontaneously  by  effusion  at  its  neck  and  the  innate  contrac- 
tility of  the  sac  itself. 


EEDUCIBLE   HEENIAS.  25 


EEDUCIBLE   HEENIAS   IN  GENEEAL. 

The  etiology  of  reducible  hernia  has  been  sufficiently  given  in 
the  preceding  pages  to  fully  show  its  course  and  progress. 

Symptomatology. — The  symptoms  are  plain  and  easily  understood, 
and  it  is  scarcely  possible  to  make  a  mistake.  When  small  as  a 
knuckle  it  may  protrude,  producing  slight  pain  and  soreness ;  but 
upon  reclining  it  will  usually  go  back  of  itself,  or  by  putting  the 
finger  on  it,  it  wiU  slip  back,  and  when  the  finger  is  taken  away  it 
will  return.  This  is  especially  the  case  where  the  tumor  is  formed 
of  intestine  alone,  but  where  the  tumor  is  larger,  and  contains 
intestine  and  omentum,  it  will  not  return  so  easily,  and  has  a 
more  firm  and  doughy  feel,  and  when  returning  will  not  emit  so 
perceptible  a  gurgling  sound.  If  the  contents  are  omentum  alone 
there  will  be  no  gurgling,  but  it  will  slip  through  its  opening  into 
the  abdomen  with  a  sudden  jump  or  spring,  described  by  some  as 
as  a  "flip"  or  "flap."  Flatulent  rumbling  or  borborygmi  are 
common  in  a  large  hernia,  when  it  has  intestine  in  it,  whether 
attended  with  omentum  or  viscera.  In  the  reduction  of  ovarian 
hernia,  it  feels  as  if  a  wad  was  tightly  pressed  in  a  hole,  and  when 
we  have  pushed  it  out,  it  seems  to  roll  from  under  our  finger.  In 
diaphragmatic,  intestinal  and  invaginal,  there  are  no  well-known 
signs,  while  they  are  reducible,  except  a  tightness  and  soreness  in 
their  seat,  relieved  by  rest  in  the  horizontal  position,  and  the 
administration  of  mild  purgatives.  In  obturatical  and  ischiatic, 
there  is  a  fullness  and  pressure  that  may  be  relieved  by  pressing 
down  on  the  point  of  protrusion,  which  wiU  return  upon  getting 
up,  riding,  coughing,  or  defecating.  Vesicocele  is  known  by  painful 
micturition  and  an  inability  to  completely  empty  the  bladder. 

Hernia  in  the  crural  region  may  be  confounded  with  a  psoas 
abscess  or  an  inflamed  lymphatic  gland,  several  instances  of  which 
have  come  under  my  observation.  A  psoas  abscess  pointing  under 
the  ilio-pubic  ligament  has  motion  in  coughing,  and  fiUs  in  standing, 
and  returns  in  the  horizontal  position ;  has  no  heat  of  consequence, 
and  requires  a  careful  study  to  diagnose  it  from  hernia,  as  I  have 
shown  in  a  case  of  psoas  abscess  reported  in  the  Nashville  Medical 
Record,  and  copied  into  the  Galveston  Medical  Journal  (see  vol.  1, 
1866). 

A  hernial  protrusion  in  this  site  is  usually  more  tense  than  an 
abscess;  has  not  so  much  mobility;  is  generally  attended  with 
3 


26  HERNIA. 

gurgling  or  crepitating  sound,  and  may  be  pushed  back ;  will  not 
return  unless  patient  exerts  bis  muscles,  while  the  abscess  will 
reform  soon  after  taking  off  your  fingers.  There  is  no  "flip"  or 
"flap"  in  pushing  back  an  abscess.  An  abscess  generally  forms 
imperceptibly  and  without  pain  in  this  region,  generally  attended 
with  pain  in  the  back  and  a  broken-down  and  ansemic  constitution, 
confining  the  patient  to  his  bed,  while  in  hernia  the  patient  is 
generally  otherwise  healthy.  An  inflamed  lymphatic  gland  may 
give  us  some  trouble,  especially  in  very  fat  persons;  two  cases  I 
have  met  with  were  really  embarrassing.  Upon  pushing  down 
the  gland  it  would  appear  to  slip  out '  of  our  reach,  and  be 
retained  either  under  the  folds  of  the  skin  and  fascia,  or  roll 
under  the  ilio-pubic  ligament,  and  there  remain  for  a  while ;  but  it 
would  again  return.  These  cases  were  diagnosed  by  the  neck  or 
attachment  being  felt  and  traced  up  to  the  gland,  but  two  cases 
reported  in  the  Galveston  Medical  Journal,  and  copied  in  this  work, 
will  show  that  a  mesentery  and  gland  may  become  strangulated 
and  simulate  -  an  inflamed  gland  so  as  not  to  be  distinguished, 
except  by  an  incision,  which  was  made  in  both  these  cases.  An- 
eurisms are  also  sometimes  mistaken  for  reducible  hernias  in  the 
femoral  variety,  as  the  hernia  lies  immediately  over  the  femoral 
artery,  or  close  by  its  side. 

Both  may  be  formed  suddenly,  but  an  aneurism  will  become  of 
large  size  and  pulsate,  while  the  hernia  must  necessarily  be  of  small 
size,  and  most  always  of  the  enterocele  variety,  and  may,  with  care, 
be  entirely  removed  by  taxis,  which  cannot  be  done  in  an  aneurism. 
It  can  be  reduced,  but  will  immediately  return  on  taking  off  the 
pressure.  Prognosis  is  nearly  always  favorable,  but  depends  almost 
entirely  on  its  treatment. 

TREATMENT  OF   REDUCIBLE   HERNIA. 

The  treatment  consists  of  two  processes.  Palliative  and  Curative. 
The  palliative  consists  of  means  to  restore  and  keep  back  the  pro- 
trusion within  the  natural  walls,  by  methods  with  trusses,  elastic 
bands,  adhesive  strips,  compresses,  and  roller  bandages.  The 
method  by  tricsses  is  the  one  usually  adopted,  and  is  the  safest  and 
best.  Trusses  are  made  of  various  shapes  and  styles,  all,  however, 
having  a  spring  and  pad,  to  fit  over  the  rupture,  or  a  pad  and 
elastic  band  attached  to  keep  up  constant  pressure. 

The  spring  is  always  made  of  steel  plate  or  annealed  wire,  and 


VARIOUS   STYLES   OF   TRUSSES. 


21 


covered  witli  leather  or  hard  rubber,  witb  the  pad  attached  to  one 
end  and  a  leather  strap  to  buckle  around  the  body  at  the  other. 
The  spring  is  so  bent  as  to  bring  the  pad  immediately  over  the  in- 
ternal opening  and  completely  cover  it  up.  Pads  are  now  usually 
made  of  ivory,  wedgewood  or  amalgam,  bone,  glass,  wire,  hard  rub- 
ber, beech,  cedar,  celluloid,  or  boxwood,  and  rarely  of  leather  stuffed 
with  hair,  wool,  or  filled  with  air.  Some  are  made  double,  some 
single,  some  with  concave  surface,  some  with  a  ring  or  small  convex 
points,  as  Marsh's  radical  cure  truss,  but  most  of  them  with  convex 
surface ;  some  of  a  horse-shoe  or  ring  shape  (J.  Wood's) ;  some  with 
a  triangular  pad.  Their  variety  is  almost  infinite.  The  object  of 
them  all  is  to  make  pressure  over  the  orifice,  with  their  backs  flat, 
for  screws,  to  regulate  the  amount  of  pressure  and  its  immediate 
direction. 


Fig. 


Double  Truss,  with  Counter-pad. 
VARIOUS   STYLES   OF   TRUSSES. 

Every  variety  of  hernia  requires  a  variety  of  truss  to  fit  it,  as 
one  for  left  and  right  side,  in  cases  of  inguinal,  scrotal,  crural,  and 
femoral.  Most  trusses  have  a  counter-pad  placed  over  the  spine, 
which  is  often  unnecessary  and  in  the  way.  See  Sheldon's  Trusses, 
Fig.  8. 

Trusses  should,  as  near  as  possible,  comprise  a  retaining  bandage, 
and  the  principles  of  a  radical  cure,  and  consequently  should  be 
applied  either  by  the  maker  himself  or  some  good  surgeon,  with 
quite  a  number  to  choose  from,  for  a  bad  fitting  or  a  badly  con- 
structed truss  may  become  dangerous,  by  allowing  the  contents  of 
the  sac  to  slip  under  it,  and  thereby  be  compressed  and  assist  in 
producing  strangulation,  as  occurred  in  the  case  of  McKim  Lea. 
See  case  reported  under  Strangulated  Hernia. 


28 


HERNIA. 


For  a  southern  climate  I  mucli  prefer  trusses  made  witli  steel 
springs  galvanized  or  covered  with  hard  rubber  or  celluloid,  pad 
made  of  hard  rubber,  ivory,  celluloid  or  amalgam,  so  they  will  not 
rust,  whether  they  are  covered  or  not.  A  very  excellent  kind  are 
made  by  Messrs.  Bock,  of  New  Orleans,  Seeley  and  Penfield,  of 
Philadelphia,  and  Dr.  Eiggs,  of  New  York,  the  original  inventor 
of  hard  rubber  trusses. 

Every  person  laboring  under  hernia  should  provide  himself  or 

herself  with  two  trusses,  that,  in  case 
the  spring  breaks,  another  may  be  at 
hand  to  put  in  its  place. 

Whatever  variety  is  used,  and  for 
whatever  kind  of  hernia,  the  truss 
should  be  worn  constantly,  night  and 
day,  if  the  patient  expects  to  be  radi- 
cally cured,  as  every  return  of  the 
hernia  will  leave  the  opening  as  patu- 
lous as  before,  and  if  it  cannot  be 
worn  while  in  bed,  it  should  be  put 
on  before  getting  up,  or  doing  any 
work.  The  hernia  should  always  be 
replaced  when  it  returns,  as  it  will 
soon  become  impacted  or  strangulated 
if  left  out. 

For  very  young  children,  an  elastic 
truss  should  be  worn,  and  for  adults, 
where  the  ordinary  truss  cannot  be 
retained  while  in  bed.  In  umbilical  and  ventral  hernias,  the  elastic 
bands  shown  in  Fig.  9  should  be  worn,  with  a  compress  under  the 

Fig.  10. 


Hirscli's  Truss,  with  Elastic  Bands. 


Abdominal  Supporter. 


VARIOUS  STYLES   OF   TRUSSES. 


29 


truss;  or  an  abdominal  supporter,  see  Fig.  10;  or  a  retentive  strap 
and  roller  bandages  may  be  used  where  supporters  cannot  be  had ; 
these  will  assist  in  making  a  radical  cure,  and  might  well  be  sub- 
stituted for  a  truss  in  children. 

In  spring  trusses  for  direct  inguinal,  crural,  and  femoral  hernias, 
there  usually  is  a  peritoneal  band  attached,  as  seen  in  Fig.  21, 
otherwise  the  pad  is  liable  to  slip  up  fig.  ii. 

or  to  the  right  or  left  of  the  orifice, 
and  thereby  become  dangerous.  A 
most  valuable  set  of  elastic  trusses 
has  been  invented  and  put  into  use 
by  J.  I.  Hirsch,  of  Germany.  We 
give  diagrams  of  the  principal  varie- 
ties, and  manner  of  their  applica- 
tion. The  one  shown  in  Fig.  11  is  especially  useful  in  vaginal  and 
rectal  hernias,  and  with  a  different  kind  of  pad  will  be  found  very 
useful  in  recent  umbilical  hernias.  Figures  12  and  13  are  modifi- 
cations of  the  same  principle. 


Elastic  Vaginal  Truss. 


Fm.  12. 


Fig.  13. 


Hirsch's  Elastic  Umbilical  Trass,        Hirsch's  Elastic  Truss,  with  Perineal  Band. 


The  great   advantage  of  these  trusses  is   their   convenience ; 
they  can  be  worn  night  and  day,  but  they  are  not  so  safe  as  the 


30 


HEENIA. 


spring  truss,  and  they  will  not  last  so  long,  and  will  soon  become 
offensive  from  absorption  of  the  perspiration. 

The  spring  of  a  truss  is  sometimes  so  strong  as  to  predispose  to 
hernia  of  the  opposite  side.  All  very  fat  persons  have  to  wear  a 
strong  spring  truss,  and  then  it  is  best  to  use  Wood's,  Fig.  14, 


Fig.  14. 


Fig.  15. 


Truss  with  Strong  Spring. 

which  has  two  pads,  one  for  the  hernial  side,  which  is  retentive, 

and  the  other  for  the  opposite  side,  which  is  preventive.     When  the 

testicle  has  not  descended 
nearly  all  are  badly  borne, 
but  it  is  still  necessary  to 
support  the  part,  and  I  there- 
fore prefer  the  elastic  band- 
age shown  in  Fig.  15,  from 
Gemrig. 

John   Wood,   of   London, 
recommends  the  horse-shoe, 

ring,  or  triangular  pad  for  large  hernias. 

Thompson's  truss  has  a  door  spring  to  its  lock.     Whit's  truss 

has  gun-lock  springs  attached  to  usual  spring.     Marsh's  radical 

cure  truss  has,  for  its  ventral  surface,  half  a  dozen  small  oblong 

balls,  forming  a  kind  of  ring. 

The  Maidstone  truss  allows  the  pad  to  shde  on  the  spring,  and 

aUows  the  instrument  to  adapt  itself  to  the  movements  of  the  body. 
Solomon's  truss,  modified  by  Eldy,  Sherman,  and  others,  allows 

the  pad  to  revolve  on  a  ball  and  socket,  to  adapt  it  to  a  right 

or  left  hernia. 


Elastic  Bandage. 


VAEIOUS  STYLES   OF   TEUSSES. 


31 


Fig.  16. 


Elastic  Truss,  with  Perineal  Band. 


Fig.  17. 


Single  Celluloid  Truss,  No.  2,  with  Counter-pad. 


Fig.  18. 


Umbilical  Trues. 


32  HEENIA. 

Edwards'  truss  allows  tlie  pad  to  both  slide  and  revolve,  and  is 
adopted  (in  principle)  by  Sheldon,  of  New  York. 

Sheldon's  truss  has  two  pads,  both  of  wood ;  one  semilunar  and 
the  other  cylindrical.  The  latter  rests  partially  in  the  crescentic 
margin  of  the  former,  thus  admitting  of  more  concentrated  pres- 
sure. The  Sheldon  truss  is  Prof.  Gross'  favorite;  he  says,  in  vol.  i, 
p.  573,  "  The  most  elegant  truss  at  present  manufactured  in  this 
country  is  that  of  Dr.  Sheldon,  the  inguinal  variety  of  which  is 
represented  in  Fig.  430.  The  pad,  made  of  boxwood,  is  of  the 
semicircular  shape,  and  is  connected  with  an  oblong  compress  com- 
posed of  the  same  materials  but  smaller,  and  so  arranged  as  to 
bear  on  the  inguinal  canal."  In  other  respects  it  does  not  differ 
from  the  more  ordinary  trusses. 

Nuson's  truss.  The  spring  is  made  of  round  wire  instead  of  the 
usual  flat  band  of  steel.  See  Pomeroy's  amalgam  wire  truss,  on 
same  principle. 

Mock  Main  truss  is  a  simple  band  or  belt. 

Bouigereaus'  and  Hirsch's  trusses  are  elastic  bands  of  india-rub- 
ber webbing.  Dr.  House's,  of  New  York,  is  the  same,  and  a  good 
truss  of  its  kind. 

Before  applying  any  truss  the  part  over  which  the  pad  fits  should 
be  well  bathed  with  alum  and  whisky,  cologne  water,  sugar  of 
lead  water,  bay  rum,  or  solution  of  tannin,  to  prevent  chafing  and 
tenderness,  and  if  it  becomes  painful,  the  spring  truss  should,  for  a 
while,  be  substituted  by  an  elastic  band.  This  is  best  in  all  cases 
of  very  young  children.  Great  attention  should  be  paid  to  clean- 
liness, especially  where  a  perineal  strap  has  to  be  worn,  and  par- 
ticularly in  nursing  children. 

The  ratio  of  radical  cures  by  the  truss  is  in  proportion  to  age, 
the  time  of  protrusion  of  the  tumor,  and  the  size  of  the  orifice  and 
tumor.  The  small  size  being  often  cured  in  those  free  from  obesity, 
while  in  very  large  hernias  the  probabilities  of  a  cure  are  very 
slight,  from  the  want  of  plastic  material  to  fill  up  so  large  an  open- 
ing ;  hence,  few  cases  are  ever  thoroughly  cured.  But  most  all 
cases  are  lessened  and  improved  by  the  constant  use  of  a  good  and 
well-fitting  truss,  which  produces  adhesive  inflammation.  "  The 
sooner,  therefore,  a  truss  is  applied,  the  better  it  fits,  and  the  more 
steadily  it  is  worn,  the  greater  will  be  the  chances  of  a  speedy  and 
permanent  cure  "  (Gross).  Congenital  oblique  hernia  can  almost 
always  be  cured  by  a  good  truss  constantly  worn,  night  and  day. 


VAEIOUS  STYLES  OF  TEUSSES. 


33 


Fig.  19. 


Single  Celluloid  Truss,  No.  3. 


Fig.  20. 


Penfleld's  Set-Screw  Truss. 


Fig.  21. 


Qerman  Truss,  with  Perineal  Band. 


34  HERNIA. 

All  cases,  as  we  have  before  said,  are  benefited,  wbether  large  or 
small,  old  or  young,  or  however  unfavorable  they  may  appear.  No 
hernia  should  be  left  without  a  support  sufficient  to  retain  the  her- 
nia reduced.  In  ordering  a  truss  for  epigastric  hernia,  the  measure 
should  be  taken  around  the  body  with  a  tape  measure,  or  with  soft 
and  flexible  wire,  horizontally  over  the  opening.  The  same  for 
umbilical  and  ventral,  in  the  median  line,  with  the  additional  meas- 
ure from  the  umbilicus  and  the  pubis.  In  all  lateral  hernias  it 
should  be  specified  whether  right  or  left,  or  double.  For  inguinal 
hernia  the  tape  or  wire  should  be  drawn  around  the  smallest  part 
of  the  abdomen  above  the  ileum,  and  entirely  around  the  body, 
marking  where  it  crosses  the  spine  with  another  from  its  nearest 
point  to  the  hernial  orifice,  and  from  this  orifice  to  the  line  just 
above  the  ileum,  whether  in  the  inguinal  or  crural  region.  See 
diagram,  Figure  2  (0),  page  13. 

Belts  around  the  body  are  numbered  in  figures ;  perpendicular 
line  with  letter  (a).  1,  epigastric — B. 

1st.  Epigastric,  2d.  Hypochondric,  3d.  Lumbral,  4th.  Umbilical, 
5th.  Ventral  and  Lumbral,  6th.  Inguinal  Scrotal.  Crural  and  Fem- 
oral (A)  perpendicular  lines,  to  belt  (B)  oblique  lines. 

For  epigastric  hernia  measure  in  lines  (1)  A  and  B.  Give  with 
size  of  orifice  thus:  (1),  22  inches,  (A),  4  inches,  (B),  6  inches. 
From  this  measure  any  maker  can  fit  your  patient  satisfactorily. 

Where  patient  finds  any  deficiency  in  an  old  truss,  it  should  be 
marked  and  sent  to  the  maker  to  be  corrected,  with  the  above 
measures.  With  these  simple  and  plain  rules  any  non-professional 
person  can  order  his  own  truss,  and  by  stating  what  maker  he 
wants,  as  named  in  our  list  and  shown  by  diagrams,  he  will  get  just 
what  he  desires.  I  have  given  in  the  appendix  the  prices  in  Phila- 
delphia, New  York,  and  New  Orleans,  the  lowest  price  indicating 
the  simplest  and  cheapest  material ;  the  highest,  the  best  and  finest 
finish  ;  but  both  alike  efficient  and  not  difiering  materially  in  the 
make  of  the  spring. 

RADICAL  CURE   OF    HERNIA. 

We  shall  treat  of  this  subject  under  two  heads,  Process  and 
Method,  and  shall  take  up  the  oldest  process  first,  and  the  oldest 
and  least  successful  method  of  any  process,  leaving  for  the  last  the 
best.     Lastly,  best  process  and  best  method. 

The  process  by  truss  has  been  fuUy  explained  under  the  head  of 


VAEIOUS  STYLES  OF  TRUSSES. 


35 


Fig.  22. 


Single  Celluloid  Truss,  No.  5. 


Fig.  23. 


Double  Celluloid  Truss,  No.  9. 


Fig.  24. 


Single  Celluloid  Truss,  No.  10. 


36  KERNIA. 

reducible  hernias  and  their  treatment,  and  need  not  be  repeated. 
Tbis,  undoubtedly,  was  the  oldest  process,  and  the  retention  by- 
bandages  the  first  metbod  of  tbis  process.  Finding  it  entirely  in- 
efficient to  retain  the  hernia  reduced,  the  ancient  physicians  re- 
sorted to  rudely  constructed  trusses  with  steel  springs,  which  have 
come  down  to  our  day,  but,  as  we  have  seen,  greatly  improved  and 
almost  perfected,  the  best  trusses  being  Pomeroy's,  Sherman's,  See- 
ley's,  Sheldon's,  Penfield's  and  Marsh's.  Illustrations  of  several  of 
these  are  given  herewith. 

Among  the  many  great  advantages  claimed  for  E.  0.  Penfield  & 
Co.'s  Celluloid  Truss,  are  the  following: — It  wiU  not  rust,  break,  or 
wear  out;  it  is  always  clean;  it  can  be  worn  in  sea  bathing;  it  is 
not  afiected  by  perspiration;  it  is  not  affected  by  heat  or  cold;  it 
is  readily  adjusted;  it  is  free  from  any  unpleasant  odor;  it  always 
retains  its  position.  These  are  but  a  few  of  the  many  reasons  why 
the  Celluloid  Truss  is  the  best,  cheapest,  most  durable  and  only  per- 
fect truss  ever  yet  made.  In  addition  to  these,  E.  0.  Penfield  &  Co. 
manufacture  over  150  varieties,  and  any  special  pattern  desired. 
The  address  of  this  firm  is  No.  112  S.  Eighth  Street,  Philadelphia. 

Upon  the  discovery  of  India  rubber,  it  was  used  for  making 
trusses  without  springs,  which  we  have  shown  are  very  useful,  and 
of  special  advantage  in  treating  very  young  children,  and  when 
spring  trusses  could  not  be  worn  at  night  as  well  as  during  the  day. 

AU  these  methods  fail  in  old  cases  and  of  large  size.  Those  best 
adapted  to  such  treatment  are  inguinal-oblique,  femoral,  crural, 
and  umbihcal,  especially  congenital  inguinal-oblique,  scrotal,  and 
umbilical,  cures  rarely  ever  being  effected  in  any  other  varieties. 
These  failures  induced  surgeons  to  try  other  processes  and  methods. 

OTHER  METHODS  AND   PROCESSES. 

Incisions  were  practiced  from  the  remotest  times  to  the  seven- 
teenth century,  and  even  later,  and  are  now  practiced  by  the  bar- 
barous and  uneducated. 

1.  The  first  method  was  to  cut  out  the  sac  and  suffer  the  parts 
to  heal  up,  which  was  introduced  from  the  necessity  of  cutting 
down  in  cases  of  strangulation,  and  as  cures  had  occurred  after 
strangulation  by  granulation,  this  was  the  principal  method  for  a 
long  time,  but  proved  to  be  very  dangerous  and  unsuccessful, 
hence  it  was  abandoned,  and  the  method  of  cutting  down  and  ligat- 
ing  the  sac  was  introduced. 


PROCESS   BY   PLUGGING  AND   INVAGINATION.  37 

2.  Method  hy  exposure  of  sac  and  putting  a  ligature  around  ita 
neck.  This  was  an  improvement,  as  it  prevented  death,  from  hem- 
orrhage and  did  not  expose  the  peritoneum ;  but  this  was  also 
dangerous,  and  was  finally  abandoned  for  want  of  success. 

3.  Incision  of  the  sac  and  the  application  of  irritants  to  cause 
inflammation,  and  thereby  produce  obliteration. 

Process  hy  removal  of  sac  and  scrotum  in  scrotal  hernia.  This 
was  a  barbarous  and  wicked  practice,  but  was  much  followed  up  to 
and  even  during  the  seventeenth  century ;  and  it  is  said  that  an 
itinerant  operator  in  Europe  fed  his  dogs  on  the  testicles  he  thus 
removed  (Gross).  This  barbarous  and  wicked  process  was  finally 
put  down  by  law,  but  was  followed  by  other  methods  alike  danger- 
ous and  cruel,  as  that  of  Belmas. 

Belmas  Method. — He  cut  down  on  the  neck  of  the  sac,  and  put 
over  its  orifice,  along  its  neck,  bladders  of  gold-beater's  skin, 
with  the  view  of  making  pressure  on  the  neck  and  causing  adhesive 
inflammation,  thereby  promoting  its  closure ;  but  his  plan  proved 
unsuccessful  and  dangerous,  and  it  is  now  entirely  abandoned. 

PROCESS   BY   PLUGGING  AND   INVAGINATION. 

Among  the  earliest  methods  by  this  process  was  that  of  Gerdy's. 

Gerdy's  Method. — He  pushed  up  a  fold  of  the  skin  and  fascia 
into  the  neck  of  the  sac,  as  far  as  possible,  and  then,  with  a  curved 
needle,  he  pierced  the  folds  of  skin,  muscle  and  fascia  of  the  super- 
imposed parts,  pushing  the  strong  curved  needle,  double  threaded, 
to  the  right  and  left,  about  one-third  of  an  inch  from  each  other. 
These  threads  were  then  tied  over  pieces  of  bougie,  and  left  to  pro- 
duce adhesive  inflammation.  The  invaginated  portion  was  then 
denuded  of  its  cuticle  with  spirits  of  ammonia,  and  pressure  made 
over  it  to  produce  adhesion  of  its  sides.  This  was  also  unsuccess- 
ful in  most  cases,  and  was,  like  the  truss,  only  adapted  to  oblique 
inguinal  hernias.  When  the  threads  were  taken  out  the  invagi- 
nated plug  came  down,  and  with  it  the  hernia.  Nor  was  this 
process  free  from  danger,  as  shown  from  sixty-two  cases  collected 
by  Therry ;  four  died  and  only  a  few  were  permanently  cured.  Of 
all  the  methods  heretofore  used,  Gerdy's  was  the  best,  and  it  has 
no  doubt  led  to  other  processes  and  methods,  as  that  of  scarifica- 
tion of  the  neck  and  pressure ;  but  before  speaking  of  this  process, 
let  us  finish  the  methods  by  plugging,  which  have  been  the  most 
successful  and  popular.      Dr,  J.  Jameson,  of  Baltimore,  cured  a 


38  HERNIA. 

case  of  femoral  hernia,  as  early  as  1828,  by  dissecting  up  a  tongue- 
Kke  flap  from  the  neighborhood  of  the  ilio-pubic  ligament,  and  in- 
serting a  portion,  three-quarters  of  an  inch  thick,  into  the  femoral 
canal,  and  closing  the  wound  by  several  sutures  over  the  inserted 
flap.  The  transplanted  flap  became  a  hard  knot  and  completely 
closed  the  opening;  this  proved,  in  one  case  (that  of  a  lady),  a  perfect 
success.  We  do  not  know  whether  he  ever  repeated  it  or  had  any 
followers,  except  Bedford  Da  vies,  of  Birmingham,  England,  who 
treated  a  case  with  a  hard  plug.  His  patient  died  some  time  after- 
ward, but  not  from  the  operation.  This  method  carries  with  it  the 
principles  of  success,  in  femoral  and  crural  hernia,  where  the  walls 
of  the  rupture  are  small  and  cannot  be  distended,  but  is  not  at  all 
adapted  to  any  other  variety. 

Wurtzer's  Method. — In  1833,  Wurtzer,  of  Bonn,  in  Germany, 
invented  and  used  an  instrument  for  the  radical  cure  of  hernia.  This 
instrument  carries  out  the  idea  of  Gerdy  in  a  very  simple  manner, 
and  one  measurably  free  from  danger.  Its  action  is  the  same  as 
that  of  Gerdy 's,  that  is,  by  invaginating  a  portion  of  the  skin  and 
fascia,  holding  it  there  until  inflammation  unites  the  invaginated 
portions. 

Fig.  25, 


Wurtzer's  Instrument. 

The  instrument  is  composed  of  three  essential  parts — a  wooden 
(or  as  now  made,  a  hard  rubber)  cylinder,  a  long  curved  needle, 
and  a  cover  for  making  external  pressure.  The  cylinders  are 
made  of  difierent  sizes,  to  fill  small  or  large  openings,  as  in  children 
and  adults.  They  are  usually  three  inches  long  and  three-eighths  to 
three-quarters  of  an  inch  in  diameter,  of  a  flattened  shape,  and 
perfectly  smooth  and  rounded  at  their  points,  with  a  hole  through  the 
centre  coming  out  behind  the  point,  about  one-quarter  of  an  inch, 
on  the  upper  side.  When  put  in  operation,  the  needle  is  entirely 
concealed  in  its  length,  except  at  its  point,  where  it  comes  through 
the  superimposed  integument  and  passes  through  a  slit  in  the 
external  plate.     The  handle  of  the  needle,  as  well  as  its  point,  is 


PEOCESS   BY  PLUGGING  AND   INVAGINATION.  39 

made  movable,  and  when  in  use  both  are  taken  off  and  brass  knobs 
screwed  in  their  place.  The  cover  is  concave,  to  fit  over  the  cylin- 
der and  to  closely  compress  the  inclosed  folds  when  in  use. 

The  mode  of  applying  Wurtzer's  instrument  is  simple  and  easy. 
The  parts  being  well  shaven,  and  the  bowels  moved  several  hours 
before  the  hernia  is  reduced,  the  integuments  are  pushed  up  as  far  as 
possible,  with  the  index  finger  of  the  left  hand,  with  its  palmar 
surface  turned  upward  and  forward.  The  cylinder,  with  the 
plate  and  needle  removed,  is  guided  by  the  finger,  and  the  finger 
gradually  withdrawn  as  the  instrument  is  put  in  place.  The  point 
of  the  cylinder  should  be  well  placed  in  the  internal  ring  and  then 
pushed  up  as  far  under  the  tendons  as  possible,  and  there  held  until 
the  needle  is  passed  through,  and  the  external  plate  well  screwed 
down,  being  well  assured  that  the  instrument  is  firmly  fixed  under 
the  tendons,  which  will  be  loose  if  below  the  internal  orifice ;  if, 
in  very  relax  cases,  it  has  been  placed  above  the  ring  in  the 
cellular  tissue  above  the  tendon,  it  must  be  withdrawn  and  care- 
fully placed  under  the  tendons,  as  directed.  The  handle  of  the 
needle  is  then  unscrewed  and  a  brass  knob  screwed  in  its  place. 
The  movable  point  is  also  taken  off  and  a  brass  knob  put  on.  The 
apparatus,  thus  fixed  in  place,  is  left  in  from  six  to  eight  days, 
when  it  is  taken  off  and  a  truss  applied.  The  patient  must  still 
keep  his  bed  for  eight  or  ten  days,  until  all  soreness  leaves  the  part, 
and  he  can  bear,  without  pain,  the  truss.  The  diet  should  be  plain 
and  mostly  solid;  the  actions  and  pains,  if  any,  are  controlled  by 
morphine.  The  puncture  of  the  needle  will  generally  begin  to 
suppurate  on  the  fourth  day,  and  should  there  be  much  pain  the 
plate  may  be  loosened  by  turning  the  screw,  or  if  the  part  becomes 
loose  it  may  be  easily  tightened  by  turning  down  the  screw. 

Dr.  Otto  "Weber,  of  Bonn,  writes  to  Mr.  Beckett,  that  of  four- 
teen cases  operated  on  by  Prof.  Wurtzer,  not  one  was  radically 
cured;  "  that,  first,  the  plug  of  skin  is,  by  degrees,  entirely  drawn 
out  again ;  secondly,  that  the  true  hernia  apertures,  the  external 
and  internal  rings,  are  not  closed  by  the  operation;  thirdly,  that 
an  imperfect  cure  may  be  effected  by  means  of  a  partial  closure,  by 
adhesion  of  the  internal  walls  of  the  neck  of  the  hernial  sac,  and 
thickening  of  the  surrounding  connective  tissue."  In  this  country 
I  believe  the  same  report  might  be  made.  It  utterly  failed  in  aU 
the  cases  operated  on  by  the  author,  but  a  better  success  has  attended 
Prof.  May's  operations  and  operators  in  London. 


40  HERNIA. 

Rothmund's  Method. — He  used  an  instrument  witli  three  needles, 
one  in  the  centre,  one  on  each  side,  with  a  cylinder  completely 
filling  the  orifice,  made  larger  by  layers  on  the  sides  of  Wurtzer's 
instrument.  He  reports,  up  to  1853,  one  hundred  and  forty  cases, 
with  the  following  results : — 117  cured,  4  amehorated,  6  not  bene- 
fited, and  13  relapsed.  "  Of  the  latter,  some  were  radically  cured 
by  being  operated  on  a  second  time." — Gross. 

Owing  to  the  failures  with  "Wurtzer's  instrument,  I  set  myself 
to  work  to  make  improvements  on  his  process.     In  the  fall  of  1858 

1  invented  a  similar  instrument. 

This  instrument  consists  of  two  plates  screwed  together  by  the 
screw  No.  2,  which  separates  the  two  valves  by  the  lower  nut, 
and  opens  them  to  any  desired  extent,  as  pressure  is  made  with  the 
screw  of  a  tourniquet;  a  concave  plate,  like  Wurtzer's,  with  five  holes 
in  it,  for  five  screws.  Screws  Nos.  1  and  3  hold  the  plate  down,  and 
act  as  the  screws  in  Wurtzer's  instrument.  The  other  two  screws, 
Nos.  4  and  5,  are  made  with  a  cutting  point,  and  after  the  cylinder  is 
put  in  place,  as  in  Wurtzer's  operation,  the  plate  is  screwed  down 
by  screws  Nos.  1  and  2.  The  cylinder  still  held  steady  in  its  place, 
the  screws  are  pushed  through  into  the  first  valve  of  the  cylinder,  and 
with  their  cutting  points  into  the  second ;  the  first  valve  has  a  nut  at 
the  body  of  the  screw  with  threads  above  its  cutting  point;  the  screw 
is  firmly  screwed  into  the  first  valve,  the  nut  is  then  put  on,  and  the 
plate  screwed  down  at  its  point;  the  other  screw  is  put  in  in  like  man- 
ner. This  is  left  in,  as  in  Wurtzer's  operation,  for  six  or  eight  days, 
then  removed;  patient  should  be,  in  every  respect,  treated  as  with 
Wurtzer's  instrument.  Finding,  in  applying  this  instrument  on  the 
dead  subject  (I  have  never  used  it  on  the  living),  as  wdl  be  ex- 
plained further  on,  under  author's  method  and  process,  page  48, 
great  difficulty  in  keeping  the  cylinder  well  in  place  while  the 
screws  were  being  put  in,  I  made  a  further  modification  of  Wurt- 
zer's instrument. 

I  had  the  canal  for  the  needle  made  in  the  body  of  the  upper 
valve,  and  put  in  two  screws,  as  in  my  substitute,  to  right  and  left 
of  Wurtzer's  needle,  while  the  valves  are  separated  by  the  under 
nut,  acting  as  before,  on  the  principle  of  the  tourniquet  screw.    No. 

2  screw  passes  to  the  left  of  the  needle ;  No.  3  to  the  right. 

Now  I  claim  these  advantages  over  Wurtzer's  instrument :  First, 
the  two  valves  can  be  made,  with  the  screws,  to  separate  to  the 
desired  extent  to  fill  the  internal  orifice,  and  the  ends  are  more 


PEOCESS   BY   PLUGGING  AND   INVAGINATION.  41 

expanded  than  the  body  or  proximal  end.  The  screws  go  directly- 
through,  perpendicularly  to  the  surface,  and  through  the  invagi- 
nated  integuments,  sealing  them  up  more  closely  than  could  other- 
wise be  done,  and  the  two  screws  act  somewhat  like  the  right  and 
left  needle  of  Rothmund's  instrument.  Thirdly,  their  direct  line 
prevents  them  from  cutting  out,  as  the  needle  does  without  them. 

This  instrument  I  have  never  used  on  the  living  subject  (as  will 
be  seen)  because,  before  I  got  it  made,  I  invented  the  process  with 
the  needle,  which  I  think  fills  all  the  indications;  but  as  objec- 
tions have  been  made  to  that  process,  on  account  of  penetrating  the 
abdominal  wall,  I  have  thought  it  necessary  to  put  these  sugges- 
tions here  for  those  who  are  timid,  and  those  who  have  not  ana- 
tomical knowledge  and  tact  to  use  the  needle.  This  instrument,  as 
well  as  Wurtzer's,  is  comparatively  free  from  danger,  and  has  the 
merit  of  being  easily  applied  by  any  one,  but  is,  like  all  plugging 
operations,  only  applicable  to  oblique-inguinal,  scrotal,  and  crural 
hernia,  and  like  all  plugging  operations,  will  finally  fail,  and  the 
hernia  return  as  bad  as  ever. 

Professor  D.  Hayes  Agnew's  Method. — He  uses  an  instrument 
such  as  is  seen  in  Gross'  (new  edition)  Principles  and  Practice  of 
Surgery,  1872.  This  instrument  closely  resembles  a  bivalve  specu- 
lum, the  blades  of  which  have,  first,  two  longitudinal  grooves,  three 
inches  in  length,  and  connected  by  a  hinge  near  the  handle,  which 
is  itself  controlled  by  a  screw ;  secondly,  a  very  long,  slender  needle, 
mounted  upon  a  wooden  handle,  and  terminating  in  a  curved  point, 
pierced  by  an  orifice ;  and  thirdly,  a  common  stout  suture  needle, 
two  inches  and  a  half  in  length. 

Fig.  26. 


Dr.  Agnew's  Instrument. 

The  parts  being  well  shaved,  and  a  portion  of  scrotal  integument 
being  pushed  into  the  external  ring,  the  instrument,  with  its 
grooved  blade  looking  toward  the  abdomen,  is  employed  to  carry,  by 
gentle  but  steady  pressure,  the  invaginated  plug  to  the  upper  ex- 
tremity of  the  inguinal  canal. 

Holding  the  parts  in  these  relations,  the  surgeon  inserts  the 
4 


42  HERNIA. 

point  of  a  long  needle,  armed  witli  a  silver  wire,  into  one  of  the 
canals  of  the  inner  blade,  widely  separated  from  the  other,  and 
passing  It  on,  perforates  the  superimposed  structure.  The  needle, 
being  withdrawn,  is  then  carried  along  the  outer  gutter,  and  thence, 
in  like  manner,  across  the  tissues,  the  two  punctures  being  about 
half  an  inch  apart.  In  this  way  the  base  of  the  plug  is  thoroughly 
embraced  by  the  loop  of  wire,  the  ends  of  which  are  then  twisted 
over  a  roll  of  lint  upon  the  surface  of  the  abdomen. 

The  instrument  being  held  steady  in  its  position,  the  sides  of  the 
inguinal  canal  are  next  approximated  by  three  horizontal  sutures, 
about  half  an  inch  apart,  the  needle,  armed  with  a  stout  silk 
thread,  being  passed  between  the  blades  of  the  cylinder.  In  this 
way  all  danger  of  including  the  spermatic  cord  and  the  peritoneum 
is  effectually  avoided. 

The  operation  being  completed,  the  instrument  is  removed,  and 
the  patient,  rigidly  confined  to  bed,  is  treated  antiphlogistically. 
The  horizontal  sutures  should  not  be  removed  for  ten,  twelve  or 
fourteen  days,  or  until  there  is  reason  to  believe  that  a  sufiiciency 
of  plastic  matter  has  been  poured  out  to  insure  the  firm  union  of 
the  plug.  The  wire  thread  may,  if  necessary,  be  retained  for  an 
almost  indefinite  period. 

Mosmer's  Process. — He  passes  a  seton  longitudinally  through 
the  sac,  to  produce  suppuration  and  its  closure.  He  performed  it, 
according  to  Rothmund,  thirty-four  times,  with  twenty-nine  cures, 
two  ameliorations,  one  failure,  one  death  and  one  relapse. 

Professor  Armsby's  Method,  of  Albany,  N.  Y.  —  He  uses  a 
needle  with  a  single  thread,  which  is  introduced,  as  a  seton,  through 
the  hernial  sac  and  inguinal  canal,  bringing  it  out  above  the  inter- 
nal ring. 

The  thread  being  brought  out  by  one  end  at  the  upper  part  of 
the  internal  ring,  and  by  the  other  in  the  canal  at  the  lower  part 
of  the  scrotum,  is  occasionally  moved  in  order  to  provoke  the  re- 
quisite amount  of  inflammation.  A  truss  is  applied  for  a  few  hours 
immediately  after  the  operation. 

Br.  Biggs  MUhod  is  about  the  same.  He  uses  an  instrument 
like  a  curved  porte-aille,  invaginating  the  sac,  and  putting  in  a 
thread  or  seton,  or  ties  it  up  invaginated.  He  gives  the  results  of 
eight  cases,  two  from  his  own  practice  and  six  from  that  of  Pro- 
fessor Carnachan,  nearly  all  successful,  without  any  bad  symptoms 
having  foUowed.     Several  of  the  cases  were  of  very  long  standing. 


PEOCESS   OF   ACUPUNCTUEE.  43 

PEOCESS   BY  LIGATUEE. 

Professor  John  Wood's  Method,  of  London. — His  improved 
operation  is  thus  described  by  Druett :  The  instruments  required 
are  a  tenotome,  a  semicircular  needle  mounted  in  a  strong  handle, 
and  a  silver-covered  wire.  "  The  patient  being  laid  on  his  back, 
with  the  shoulders  well  raised  and  the  knees  bent,  the  pubis 
cleanly  shaven,  the  rupture  completely  reduced,  and  chloroform 
being  administered,  an  oblique  incision,  about  an  inch  long,  is  made 
in  the  skin  of  the  scrotum,  over  the  fundus  of  the  hernial  sac.  The 
knife  is  then  carried  flatwise  under  the  skin,  from  the  deeper  cover- 
ings of  the  sac,  to  the  extent  of  about  an  inch  or  more  all  around. 
The  forefinger  is  then  passed  into  the  wound,  and  the  detached 
fascia  and  fundus  of  the  sac  invaginated  into  the  canal.  The  finger 
then  feels  for  the  lower  border  of  the  external  oblique  muscle,  lift- 
ing it  forward  to  the  surface.  By  this  means  the  outer  edge  of  the 
conjoined  tendon  is  felt,  to  the  inner  side  of  the  finger;  the  needle 
is  then  carried  carefully  up  to  the  point  of  the  finger,  along  its  side, 
and  made  to  transfix  the  conjoined  tendon,  and  also  the  inner  pillar 
of  the  ring.  (Gross'  "  Principles  and  Practice  of  Surgery,"  1872, 
pages  577,  578,  and  579.) 

Prof.  Wood,  in  his  work  on  hernia,  published  in  1863,  gives  the 
results  in  sixty  cases.  Twenty-one  by  thread  and  compress,  twen- 
ty-seven by  various  modifications  of  the  wire  operation,  ten  by  the 
use  of  a  pair  of  pins,  two  by  pins  and  wire.  Failures,  eleven ;  five 
from  wire  and  compress.  Cures,  forty-two ;  ten  not  heard  from ; 
four  of  forty-six  cases  by  wire  failed;  two  only  of  ten  with, pins 
failed ;  six  cases  doubtful ;  sixty-five  to  seventy  per  cent,  cured ; 
three  or  four  still  under  treatment. 

PEOCESS   OF   SCAEIFYING  THE  NECK:  AND   COMPEESSION. 

Alphonse  Guerin's  Process  and  Method  consists  in  scarifying 
the  neck  of  the  sac  by  means  of  a  delicate  bistoury  introduced  sub- 
cutaneously.  Pressure  is  then  made  with  a  well-fitting  and  strong 
spring  truss,  to  approximate  the  opposed  surfaces,  in  order  to  pro- 
duce union  by  the  effusion  of  plastic  matter. 

PEOCESS   OF   ACUPUNCTUEE.. 

Bonnet's  Method,  of  Lyons,  Finance.  H&  transfixes  the  sac 
with  a  number  of  pins,  which  are  left  in  until  there  is  ulceration  of 


44  HEENIA. 

the  skin,  compression  being  used  in  the  intervals  of  the  little  in- 
struments, for  the  purpose  of  promoting  adhesive  action.  Of  eleven 
cases  thus  treated  by  Bonnet,  four  were  cured,  five  were  unsuccess- 
ful, and  two  proved  fatal. 

PROCESS   BY   INJECTION   OF   THE   SAC. 

This  process  is  in  every  respect  similar  to  the  treatment  of  hy- 
drocele by  injection,  consisting  of  the  introduction  of  some  mildly 
irritating  fluid,  as  the  tincture  of  iodine.  This  was  first  practiced 
by  Velpeau. 

G.  W.  Hinman,  m.  d.,  of  Derby,  cured  one  case  by  laying  open 
the  sac  and  brushing  the  inside  over  with  tincture  of  iodine,  patient 
doing  well  one  year  afterward.     No  mention  of  a  truss  being  used. 

pancoast's  method  and  results. 

"The  protruded  viscera  having  been  carefully  replaced,  and 
firm  pressure  being  made  upon  the  hernial  aperture,  a  drachm  of 
iodine  is  thrown  into  the  sac  and  passed  about,  so  as  to  bring  it  in 
contact  with  every  portion  of  its  inner  surface.  The  operation  is 
performed  with  a  delicate  trocar,  with  the  point  of  which  the  sac 
is  freely  scarified  before  the  fluid  is  forced  through  the  canula. 
The  injection  being  over,  a  stout  compress  is  applied  over  the  her- 
nial opening,  and  unremittingly  supported  by  the  pressure  of  a  well 
adjusted  truss.  The  iodine  is  soon  absorbed,  and  a  cure  is  pro- 
duced by  the  agglutination  of  the  contiguous  surfaces.  The  opera- 
tion, which  occasionally  requires  to  be  repeated  a  second,  and  even 
a  third  time,  must  be  performed  with  the  greatest  care,  lest  some 
of  the  fluid,  passing  into  the  abdominal  cavity,  should  cause  fatal 
peritonitis." 

Alden  Marsh  reports  four  failures  by  injection.  John  Watson, 
of  New  York,  cured  one  case  after  Pancoast's  operation ;  was  doing 
well  ten  weeks  afterward. 

REMARKS    ON    THE    PROCESSES     OF   SCARIFICATION,   ACUPUNCTURE, 

AND   INJECTION. 

"  The  cases  best  fitted  for  these  various  procedures,  as  in  the 
cases  of  plugging  above,  are  such  as  are  of  comparatively  recent 
standing,  and  unaccompanied  by  any  great  bulk  of  the  tumor. 
When  the  canal  is  much  diminished  in  length,  and  increased  in 
diameter,  as  generally  occurs  in  old  ruptures,  in  which  the  orifices 


DIRECT  PROCESS. 


45 


Fig  27. 


of  the  canal  are  ori  the  same  line,  and  imtnediately  ahove  each 
other,  a  cure  will  generally  be  impracticable  hy  any  method  what' 
ever.*  To  femoral,  umbilical,  and  ventral  hernias,  these  procedures 
are  not  adapted,  owing  to  the  great  risk  of  peritonitis  and  exten- 
sive suppuration  "  (Gross,  page  578). 

PEOCESS   BY   HARE-LIP   SUTURE. 

Prof.  S.  E.  Beckwith,  a  homoeopathic  surgeon,  of  Cleveland, 
Ohio,  reports  the  following  process  with  plates,  in  the  Medical  and 
Surgical  Reporter  (homoeopathic),  for 
May,  1872.     See  Figure  27. 

He  thus  proceeds :  replacing  the 
hernia,  the  parts  above  the  canal  are 
raised,  leaving  the  cord  below,  and 
a  needle  double  threaded  is  passed 
through  the  gathered  tissues  just 
above  the  external  ring.  Another 
needle,  like-threaded,  is  passed 
through  in  an  opposite  direction, 
about  half  an  inch  above  the  first, 
and  the  thread  wound  around  the 
needles  from  heel  to  joint. 

The  advantage  claimed  (by  its  au- 
thor) for  this  mode  of  operation  is,  that,  if  peritonitis  should  ensue, 
the  needle  can  at  once  be  removed,  and  the  threatened  danger 
be  prevented.  He  says  he  has  operated  several  times,  but  gives 
no  results.  This  method,  if  at  all  successful,  is  only  suitable  to 
oblique-inguinal  and  umbilical  hernias,  of  small  size  and  of  recent 
formation. 


Prof.  Beckwitti's  Method. 


DIRECT    PEOCESS. 

Prof.  Gross  says,  in  his  new  edition  of  Surgery,  page  578,  that 
"the  most  rational  radical  treatment  of  hernia  is  undoubtedly  the 
direct,  as  it  may  be  termed,  consisting  in  cutting  down  upon  the 
parts,  freshening  the  edges  of  the  opening  of  descent,  and  approxi- 
mating them  with  wire  sutures,  either  permanently  retained  or 
■until  complete  consolidation  has  been  effected.  The  operation,  it  will 
be  perceived,  is  founded  upon  the  same  principle  as  that  for  hare- 
lip and  cleft  palate,  and  will,  if  properly  executed,  be  much  more 


♦We  think  differently,  as  the  sequel  will  show. 


46  ^-  HERNIA. 

likely  to  answer  the  purpose  than  the  process  of  invagination  no"^ 
so  much  in  vogue,  and,  for  the  most  part,  so  worthless." 

There  is  no  doubt  but  the  direct  plan  deserves  more  attention 
than  it  has  received,  and  may  be  resorted  to  when  all  others  have 
failed.  I,  however,  cannot  see  the  necessity  of  paring  the  edges, 
as  recommended  by  Prof,  Gross,  for  certainly  the  new-cut  surfaces 
will  unite  without  it,  and  we  well  know  that  compression  alone  is 
necessary  to  cause  adhesion  in  all  serous  tissue ;  so,  even  if  the  sac 
was  opened,  this  freshening  of  the  edges  is  entirely  unnecessary. 
This  mode  of  closing  the  incision  has  been  resorted  to  by  Dr.  Rich- 
ardson, of  New  Orleans,  after  the  operation  of  strangulated  hernia, 
with  success,  and  I  myself  have  practiced  it  in  two  cases,  with 
complete  success,  as  will  be  seen  under  the  head  of  Strangulated 
Hernia. 

PEOCESS   BY   SUBCUTANEOUS   SUTURE  WITH  BRAID. 

Dr.  Thomas  "Wood,  of  Cincinnati,  April  18th,  1851,  reports  the 
following  process  and  method,  as  practiced  by  himself  on  three 
cases.  He  thus  describes  his  needle  :  "  Curved  so.  as  to  form  about 
one-third  of  the  circumference  of  a  circle  of  two  inches  radius,  it 
has  two  spear  points,  with  an  eye  in  the  centre  of  the  shaft  large 
enough  to  admit  a  silk  braid  one-eighth  of  an  inch  wide.  The 
needle  armed  with  the  braid  and  well  oiled,  patient  put  in  a  relaxed 
position,  the  little  finger  of  the  left  hand  is  passed  from  the 
bottom  of  the  scrotum  to  the  external  ring,  and  while  it  is  held 
there,  the  needle  is  thrust  through  the  integuments  so  as  to  strike 
the  inner  column  of  the  ring  about  one-eighth  of  an  inch  from  its 
margin,  and  as  near  its  attachments  to  the  pubis  as  possible  with- 
out endangering  the  cord.  When  the  proper  place  is  selected,  the 
needle  is  generally  passed  through  the  tendon  and  its  point  is 
turned  upward  as  it  is  pushed  across  the  ring  to  the  opposite 
column,  so  as  to  become  entangled  in  the  cellular  tissue  of  the 
inverted  scrotum  that  caps  the  ends  of  the  finger. 

"  When  the  point  of  the  needle  is  carried  sufficiently  far  to  reach 
the  column  opposite  its  entrance,  the  finger  is  withdrawn,  so  that 
we  may  be  certain  that  part  of  the  scrotum  hangs  on  the  needle's 
point,  and  it  is  again  introduced.  Then,  as  the  finger  is  a  second 
time  gradually  withdrawn  from  the  ring,  the  side  of  the  needle  is 
made  to  press  firmly  against  its  end,  until  the  point  is  brought 
nearly  to  the  insertion  of  the  outer  column  in  the  pubis.     The 


PROCESS  BY  SUBCUTANEOUS  SUTUEE.  47 

needle  is  then  thrust  through  the  tendons,  and  is  made  to  appear 
out  of  the  integument  on  the  opposite  side  of  the  ring  from  its  en- 
trance, when  it  is  to  be  gradually  drawn  through,  carrying  the 
ligature  with  it,  until  the  second  point  of  the  needle  escapes  from 
the  outer  column,  but  not  from  the  integument.  The  movement 
of  the  needle  is  now  reversed.  Its  inner  point  is  to  pass  over  the 
margin  of  the  outer  column,  and  under  that  of  the  inner  one,  so  as 
to  traverse  the  first  puncture  made  in  the  tendon,  which  is  now 
occupied  by  the  tail  of  the  ligature,  and  is  to  pass  out  in  the  open- 
ing in  the  integument,  stopping  when  its  first  point  arrives  at  the 
same  position  it  was  in  just  before  it  entered  the  tendon.  The  mo- 
tion of  the  needle  is  again  changed  into  progression,  and  is  made  to 
sweep  over  both  columns  of  the  ring,  on  their  anterior  surface, 
carrying  the  head  of  the  ligature  with  it  out  of  the  last  opening 
made  in  the  integuments. 

"  The  needle  is  now  removed,  leaving  the  two  ends  of  the  liga- 
ture in  the  punctures  on  opposite  sides  of  the  internal  ring.  The 
ends  of  the  ligature  are  now  to  be  drawn  firmly,  so  as  to  draw  the 
tendinous  fibres  embraced  in  the  loop  into  the  slit  made  by  the 
needle  in  the  opposite  column,  and  they  are  to  be  fixed  by  tying 
over  a  roller  laid  between  them. 

"  The  ligature  is  to  be  removed  in  ten  or  fifteen  days,  and  the 
patient  kept  in  a  recumbent  position  until  the  inflammation  has  so 
subsided  as  to  admit  of  the  pressure  of  a  truss. 

"  I  have  performed  this  operation  (slightly  modified)  on  three 
persons,  and  in  each  case  it  was  successful.  My  experience,  how- 
ever, is  too  limited  to  warrant  me  in  saying  much  in  its  favor ;  but 
I  cannot  refrain  from  expressing  the  opinion  that  it  ofi"ers  to  the 
ruptured  patient  a  better  prospect  of  a  '  radical  cure '  than  any 
operation  before  proposed." 

Dr.  Thomas  Wood,  in  a  paper  on  the  subject  of  the  "Eadical 
Cure  of  Hernia,"  read  at  the  February  (1851)  meeting  of  the 
Medico- Chirurgical  Society  of  Cincinnati,  ofiered  the  following  pro- 
positions, which  were  discussed : — 

"  1st.  Adhesions,  formed  by  inflammation  in  the  areolar  or  cel- 
lular tissue,  will  not  permanently  prevent  a  re-descent  of  the  bowels 
where  a  hernia  has  once  existed. 

"  2d.  The  insertion  of  integument  in  the  ring  and  canal,  and  the 
various  other  operations  that  have  heretofore  been  extensively  tried, 
such  as  setons,  sutures,  excision  of  the  sac,  acupuncture,  and  injec- 


48  HEENIA. 

tions,  only  join  parts  together  by  a  cellular  or  serous  membrane, 
or  a  like  new  structure,  equally  yielding  and  extensible. 

"  3d.  Artificial  cellular  or  serous  membrane  is  never  more  per- 
manent or  unyielding  tban  the  original  structures  of  tbe  same 
nature. 

"  4tli.  No  operation  can  make  a  '  radical  cure '  of  hernia  that 
does  not  offer  a  stronger  barrier  to  the  escaping  of  the  bowels  than 
cellular  or  serous  tissue." 

He  then  tabulates  the  following  as  being  the  basis  of  his  opera- 
tion : — 

"  5th.  Tendons,  when  wounded,  will  unite  again  by  a  formation 
similar  to  their  original  structure. 

"  6th.  Tendon  is  a  permanent,  unyielding  tissue,  seldom  ruptured 
by  the  strongest  exertions  of  the  body. 

"  7th.  If  we  can  close  the  external  abdominal  ring  by  a  tendi- 
nous growth,  we  may  effect  a  '  radical  cure '  of  the  hernia." 

His  operation  has  in  "  view  the  closure  of  the  external  ring  by  a 
tendinous  union  of  its  opposite  columns." 

author's  method. 

The  only  instruments  used  in  the  author's  method  are  a  double 
spear-pointed,  semicircular  needle,  with  an  eye  in  each  point  (Plate 
rv,  Fig.  1,  D),  silver  wire,  a  piece  of  cork,  soft  wood,  or  a  roll  of  adhe- 
sive plaster.  The  operation  is  performed  by  the  following  method : 
The  parts  being  well  shaven,  if  in  the  inguinal  region,  or  in  any 
site  where  there  are  hairs,  three  lines  are  then  drawn,  with  a 
small  brush  and  tincture  of  iodine,  parallel  to  the  direction  of  the 
hernial  orifice,  centre  line  immediately  over  the  internal  orifice, 
and  passing  down  to  the  external  orifice,  if  the  hernia  be  oblique- 
inguinal;  in  other  varieties  immediately  over  the  greatest  enlarge- 
ment of  the  tumor.  The  needle  is  then  taken  hold  of  by  the  left 
hand  at  its  unthreaded  end,  then  the  right  hand,  with  the  thumb 
and  forefinger,  pulls  up  the  skin  and  superficial  fascia  as  high  as  i 
can  be  done,  to  the  right  of  the  middle  line,  letting  the  middle  line 
be  just  below  the  point  of  the  thumb.  (See  Plate  iv.  Fig.  1,  A.) 
The  threaded  end  is  then  pushed  through  the  fold  held  below  the 
point  of  the  thumb  and  index  finger,  as  seen  in  position  1,  Plate 
V.  The  fold  is  then  let  loose,  and  the  threaded  end  taken  by  its 
point  with  the  thumb  and  fingers  of  the  right  hand;   it  is  then 


author's  method. 


49 


botrwirpfin  ■^t-;,-ri  '/°S'"2?  i^  '^/^■^-  I-  ^o^?°*  ^"^iW""-  C.  Third  Po3ltion.  D.  Keedle  drawn  ont,  with 
™cHnY«nJ,S  Pg^"'"?-  E.  Right  hand  elevating  Skin  and  Superficial  Fascia  in  First  Position.  F.  Lef  hand  In- 
Umbmca^^He™ia"'l?!J>T''?^w-t ''??£,'"'  ^  ^f,"""^  ^"f'""?-  Jig.  2.-Needle  and  Wires  In  Second  Position,  in 
umDiucal  Hernia.    Fio.  3.— A.  Wires  Ued,  operation  completed.    B.  Wires  in  position,  before  tying. 


50  HEENIA. 

pulled  on  until  the  unthreaded  end  comes  just  under  the  outside 
line  of  right  side  of  operator  and  left  side  of  patient,  position  No. 
2  in  plate.  The  index  finger  of  the  left  hand  is  made  to  invagi- 
nate  the  integuments  as  far  as  possible,  and  the  finger  pushed  to 
the  right,  under  the  left  tendon  of  patient,  feeling  well  the  wall. 
The  right  hand  then  raises  the  needle  so  as  to  have  its  point 
directly  over  the  point  of  the  finger  and  a  little  to  the  outside  of 
it.  The  needle  is  then  pushed  directly  down  through  the  tendon 
into  the  peritoneal  cavity;  at  this  stage  the  point  of  the  index 
finger  of  the  left  hand  is  raised  to  the  right  side  of  the  patient  and 
held  under  the  tendons ;  the  needle  is  then  moved  about,  to  see  if  it 
be  loose,  and  turned  in  its  curve,  so  as  to  carry  the  curved  portion 
of  its  point  under  the  invaginated  integuments,  etc.,  to  about  one- 
quarter  of  an  inch  of  the  right  tendon;  the  end  is  then  brought 
out  on  the  outside  line  of  the  patient's  right  side ;  this  is  done  by 
pressing  down  on  the  threaded  end  held  by  the  surgeon's  right 
hand.  See  position  ISFo.  3,  in  Fig.  1.  The  index  finger  of  the  left 
hand  is  then  taken  out  and  the  threaded  end  let  go,  and  the 
unthreaded  end  is  then  held  by  the  thumb  and  index  finger  of  the 
right  hand.  It  is  now  gently  pulled  on  until  the  threaded  end 
comes  above  the  tendon.  The  point  threaded  is  then  reversed, 
and  keeping  well  down  on  the  tendon  is  finally  pushed  out  at  the 
first  puncture  and  pulled  entirely  out,  leaving  the  two  ends  of  the 
ligature  close  together  in  the  same  puncture.  We  have  thus  put 
a  ligature  (as  seen  in  Plate  v)  entirely  around  the  two  sides  of  the 
rupture,  with  a  sufficient  portion  of  the  tendon  and  muscle  to  give 
the  thread  sufficient  surface  to  act  on  (see  B  0,  Plate  v).  And  now, 
by  pulling  on  the  two  ends,  the  rupture  is  closed  internally,  by  the 
replacing  of  its  natural  support  (see  B,  Fig.  3,  Plate  iv),  and  then 
the  ends  are  tied  around  a  roll  of  adhesive  plaster,  a  piece  of  cork 
or  soft  wood  (A,  Fig.  3).  If  one  ligature  does  not  close  the  open- 
ing so  you  cannot  push  the  joint  of  your  finger  under  the  wire, 
another  wire  is  put  in  in  the  same  way;  before  tying  the  first,  you 
may,  and  must,  put  in  enough  to  completely  close  the  rupture,  and 
they  should  not  be  more  than  a  quarter  or  half  an  inch  apart. 
The  operation  can  be  performed  from  either  side,  but  it  is  best, 
in  inguinal  hernias,  to  start  the  needle  from  the  side  opposite  to 
the  ilio-pubic  ligament.  This  enables  you  to  push  down  the  needle 
by  the  side  of  the  ligament,  but  if  you  start  on  the  side  in  the  second 
position  of  the  needle,  you  may  go  under  the  ilio-pubic  ligament. 


AUTHORS   METHOD. 


51 


Platb  V— 1.  Needle  in  First  Position.  2.  Second  Position.  3.  Third  Position.  4.  Two  ends  of  Wire  extending  from 
same  Orifice.  A.  Flap  dissected  back.  B.  Ligatures  passed  around  the  Tendons,  closing  the  Orifice.  C.  Lieature* 
coming  together  before  passing  through  the  Superficial  Fascia  and  Skin. 


52  HERNIA. 

GENERAL  REMARKS   ON  AUTHOR's   METHOD. 

This  method  is  simple  and  easy  to  perform,  and  is  applicable  to  all 
external  hernias,  direct,  scrotal,  umbilical  funicular,  inguinal,  cru- 
ral, femoral,  intestinal,  ventral,  epigastric,  hypochondric,  lumbral, 
labial,  perineal,  and  hernia  in  tunica  propria  corda  testis,  and  tunica 
propria  corda  rotunda  (in  canal  of  Nuck).  The  process  is  the  same, 
and  made  with  the  same  needle  and  silver  wire.  Of  course,  it  is 
not  applicable  to  internal  hernias,  as  diaphragmatic,  obturatic, 
ischiatic,  enterocystic,  invaginatic,  vaginal,  and  rectal;  as  they 
cannot  be  reached  without  resorting  to  the  direct  method,  which 
ought  to  be  done  in  all  cases  of  strangulated  hernia,  when  this 
needle  will  much  faciHtate  a  closure  of  the  incision,  as  will  be  seen 
in  the  report  of  cases  of  strangulated  hernia.  The  circular  form 
of  this  needle,  and  its  length,  from  four  to  six  inches,  enables  the 
operator  to  put  the  wire  through  the  incisions  from  within  to  with- 
out, on  both  sides,  by  unthreading  the  needle  and  threading  it  in 
passing  it  through  the  opposite  side.  This  will  enable  the  operator 
to  nicely  adjust  the  sides  of  the  incision,  there  being  no  folds  for 
blood  or  pus  to  intervene,  and  thereby  prevent  union  by  first  in- 
tention. 

In  the  night  of  September  10th,  1859,  while  studying  over  an 
operation  I  had  to  perform  the  next  day  with  "Wurtzer's  instrument, 
I  conceived  the  idea  of  a  shuttle  needle,  that  I  could  push  back 
and  forward,  and  thereby  inclose  both  sides  of  the  orifice  of  the 
rupture  and  pull  back  the  natural  supports  of  the  abdominal 
wall,  without  any  plug  or  invagination.  I  matured  in  my  mind 
a  needle  three  inches  long,  curved  in  the  semicircular  shape,  like 
that  of  Dr.  Thomas  Wood's,  with  two  points,  and  one  eye  in  the 
centre.  The  next  morning  I  suggested  it  to  the  medical  gentlemen 
then  present  to  see  the  application  of  Wurtzer's  instrument,  Drs. 
E.  R.  Porter,  Thomas  Brooks,  Mason  L.  Weems,  and  P.  M.  McRea> 
all  of  Columbia,  Brazoria  County,  Texas,  or  its  neighborhood.  I 
stated,  further,  that  I  believed  I  could  perform  it  with  a  very 
large  curved  surgeon's  needle.  The  gentlemen  were  all  pleased 
with  the  idea,  and  it  was  determined  I  should  try  it  on  my  present 
patient,  Abram  Thompson,  colored,  age  42  years,  he  being  in- 
formed of  the  nature  of  the  operation  and  giving  his  consent. 
Having  failed  with  Wurtzer's  instrument  in  more  favorable  cases 
than  this,  I  was  the  more  disposed  to  give  it  a  trial.  The  patient 
being  put  under  chloroform,  I  took  a  large-sized  needle,  threaded 


AUTHORS   METHOD. 


53 


PiATB  VI.— A.  Internal  Opening  of  Sac  closed  by  Wire  Ligatures.     B.  Scrotnm.    C.  Transverse  Colon.    D.  Intestine 

passing  into  Scrotum.    E.  CEecum.    F.  Testicle  on  opposite  side. 
Plate  VI— Left  Leg.— A.  Varicose  Vein  Enlarged,    B.  Varicose  Needle  in  First  Position,    C,  Second  Position,    D. 

'Operation  completed. 


54  HERNIA. 

with,  silver  wire,  and  invaginating  the  sac  with  the  index  finger  of 
the  left  hand,  I  put  the  point  of  the  needle  down  along  the  palmar 
side  of  the  finger,  and  pushed  it  through  the  invaginated  integu- 
ments, and  the  tendon  of  the  ventral  side  of  the  orifice  and  out  on 
the  inside  line,  pulling  the  needle  clean  out.  I  then  started  it  back 
along  the  wire,  and  carried  it  down  to  the  tendon,  under  the  skin 
and  superficial-  fascia,  and  out  where  I  started,  leaving  the  two 
sides  of  the  thread  together.  I  then  threaded  the  needle  with 
the  other  end,  and  passed  it  down  and  out  on  the  other  vside,  pull- 
ing it  clear  out,  and  then  back,  down  to  the  tendon  and  out  at  the 
first  puncture.  I  had  thus  inclosed  the  two  tendons,  as  I  had 
proposed,  but  on  pulling  on  the  wires,  a  puckering  at  both 
sides  showed  I  had  inclosed  a  portion  of  the  integument  on  both 
sides,  and  when  I  came  to  tie  the  ends,  they  did  not  come  up  well; 
so,  becoming  confused  at  my  failure,  I  pulled  out  the  wire  and 
applied  Wurtzer's  instrument,  as  was  first  intended.  This  cut  out 
on  the  sixth  day,  and  the  lower  end  turned  up  and  the  hernia  came 
down,  with  the  instrument  in  place.  So  I  took  it  out  and  let  my 
patient  get  well.  Unwilling  to  send  him  home  uncured,  after  keep- 
ing him  so  long,  and  he  being  very  anxious  to  be  cured,  I  pre- 
pared him  for  another  operation,  designing  to  try  this  process  over, 
or  use  Gerdy's  method.  When  the  old  wound  was  well,  and  I 
had  more  maturely  studied  over  my  process,  I  concluded  to  try 
it  again,  but  to  cross  the  ligatures  in  the  form  of  an  X,  with  all  four 
ends  of  the  wire  out  at  the  same  point. 

On  the  11th  of  October,  1859,  the  same  medical  gentlemen  being 
present,  we  put  in  two  ligatures,  exactly  as  described  above,  for  the 
one  only  making  a  cross.  The  wires  were  pulled  on,  and  showed  that 
the  orifice  was  completely  closed,  and  everything  looked  more 
favorable ;  but  there  were  still  four  points  of  puckering  at  the  four 
parts  where  the  needle  was  pulled  out  and  reinserted.  The  wires 
were  now  tied  in  a  lead  plate.  The  wires  were  kept  in  for  fifteen 
days,  and  did  not  produce  much  pain,  swelling,  or  suppuration,  and 
no  symptoms  of  peritonitis.  The  bowels  had  been  kept  quiet  with 
morphine  and  sugar  of  lead,  and  laudanum  solution  was  used  over 
the  punctures  and  on  the  testicle.  The  day  after  the  wires  were 
removed  all  seemed  well,  and  the  patient  went  down  on  the  bank 
of  the  Brazos  river  and  evacuated  his  bowels ;  he  came  back  to 
my  office  holding  his  hand  over  the  old  rupture,  and  said  he  felt 
something  give  way ;    the  next  (third)  day  the  hernia  returned. 


GENEEAL  REMARKS  ON  AUTHOR's  METHOD.        55 

We  now  sent  our  patient  off  home  and  made  the  model  of  instru- 
ment mentioned  page  40,  and  a  drawing  of  our  three-inch  needle 
with  one  eye  in  the  centre,  and  sent  them  to  Messrs.  George 
Tiemann  &  Co.,  of  New  York,  who  made  them,  and  sent  them 
to  us  on  or  about  January  1st,  1860.  Abram  was  drowned  in  the 
Caney,  in  attempting  to  swim  it,  and  we  did  not  get  any  other 
case  until  the  summer  of  1860,  when  we  were  called  by  Mr. 
Drayton,  of  Oyster  Creek,  to  treat  his  blacksmith  for  a  large 
direct  scrotal  hernia,  which  could  not  be  kept  up  by  an  ordi- 
nary truss.  We  stated  to  Mr.  Drayton  and  the  negro  man  our 
plan,  and  showed  him  our  needle.  They  both  consented  to  the 
operation.  On  September  1st,  1862,  assisted  by  Drs.  Samuel  A. 
Towsey  and  Oliver,  of  Sandy  Point,  Brazoria  County,  we  operated 
on  this  man.  When  we  came  to  try  our  three-inch  needle  in  this 
case  we  found  we  could  not  use  it,  because  it  was  too  short  to  reach 
across  the  orifice  and  out  on  the  other  side.  With  great  difl&culty 
we  did  at  last  succeed,  bat  very  imperfectly,  pulling  out  the  needle 
entirely  at  the  second  position  and  having  to  reverse  it,  as  in  the 
first  case,  with  the  surgeon's  needle.  We  also  found  that  the  wire 
in  the  centre  caught  against  the  tendons,  and  made  it  next  to 
impossible  to  pull  it  through,  bending  the  wire  at  an  acute  angle. 
We,  after  great  trouble,  thus  put  in  two  ligatures,  one  above  the 
other,  and  tied  them  over  a  small  and  soft  corn-cob,  as  we  had  no 
corks  long  enough  to  hold  both  wires.  There  was  not  so  much 
puckering  as  in  the  case  of  Abram  Thompson,  and  the  two  wires 
seemed  completely  to  close  the  orifice  and  keep  back  the  hernia  ; 
but  the  wires  were  not  close  enough  nor  high  enough  in  the  orifice, 
yet  all  seemed  favorable,  considering  the  circumstances.  The  wires 
were  kept  in  until  they  cut  out,  and  then  the  patient's  bowels  were 
moved  and  he  allowed  to  get  up ;  in  a  few  days  the  hernia 
returned,  but  not  near  so  bad  as  before;  he  could  keep  it  up 
with  a  truss. 

Case  3. — Negro  child ;  on  Mrs.  Kyle's  plantation.  Oyster  Creek ; 
male  :  about  one  year  old  :  oblique-congenital  hernia.  While  case 
No.  2  was  under  treatment,  we  were  called  to  this  case,  and,  assisted 
by  Drs.  Towsey  and  Oliver,  as  before,  we  operated  on  him,  Septem- 
ber 25th,  1862.  We  used  our  three-inch  needle  with  tolerable  suc- 
cess in  this  case,  still  finding  it  very  difficult  to  pull  the  needle 
through ;  its  shortness  did  not  give  us  leverage  enough ;  we  were 
constantly  sticking  our  fingers,  and  the  eye  being  in  the  centre  pre- 


56  HERNIA. 

vented  it  from  coming  througli  smoothly  and  without  any  jerk.  We 
put  in  one  wire  in  this  case,  it  seeming  to  be  enough  to  close  the  ori- 
fice, tied  the  wire  over  a  cork,  and  applied  a  triangular  bandage  over 
the  part,  with  the  leg  through  one  of  its  triangles,  to  prevent  the 
mother  from  moving  the  dressing.  The  patient  was  left  in  Dr.  Oli- 
ver's care,  with  instructions  to  take  out  the  wire  as  soon  as  it  got 
loose  above  the  tendons.  We  saw  it  on  the  thirtieth  day  after  the 
operation ;  the  wire  had  cut  entirely  through,  and  the  cork  was 
loose  and  movable,  with  the  wire  just  held  by  a  small  portion  of  skin. 
It  was  cut  and  taken  out — the  patient  perfectly  cured.  At  this 
visit,  a  child,  of  the  same  age  and  on  the  same  plantation,  was 
brought  to  us  suffering  from  umbilical  hernia,  produced,  as  the 
mother  thought,  from  crying  and  a  cough  from  a  cold.  It  was  as 
large  as  a  pullet's  egg,  but  easily  reduced ;  very  thin  wall,  and  readily 
compressible.  We  proposed  to  operate  with  our  needle,  which  was 
consented  to  by  the  mother  and  mistress,  Mrs.  Kyle.  Assisted  by 
Dr.  Towsey,  October  24th,  1862,  we  put  in  two  ligatures,  in  the  form 
of  an  X,  commencing  in  the  centre  and  going  to  the  right,  and 
then  down,  as  in  second  position  of  needle,  in  Plate  iv.  Fig.  2,  and 
again  out  in  third  position,  putting  a  wire  through  the  two  sides 
of  the  orifice,  clear  down  to  the  peritoneal  surface,  crossing  in  the 
centre  of  the  orifice.  The  other  was  put  in  in  the  same  way.  In 
this  case  the  walls  of  the  tumor  were  so  thin  that  we  believed  we 
put  our  needle  into  the  peritoneal  cavity  in  passing  it,  in  the  first 
position.  The  wires  were  tied  over  a  piece  of  cork  and  patient  left 
in  charge  of  Dr.  Towsey,  with  directions  to  take  out  the  wire  when 
the  cork  became  loose  and  movable.  I  did  not  see  this  case  any 
more,  but  I  have  Dr.  Towsey's  certificate  to  the  perfect  cure  of 
this  case  and  Case  3,  and  that  they  remained  cured  up  to  last  sum- 
mer, 1876,  when  we  had  the  last  report  of  them ;  they  were  then 
large  boys,  over  fourteen  years  having  elapsed.  Finding  so  much 
trouble  with  our  short  needle,  we  abandoned  the  operation,  and 
refused  to  operate  any  more  until  we  could  get  a  larger  needle,  and 
one  grooved  like  the  one  we  now  use.  I  wrote  a  long  letter  to 
Prof.  Frederick  May,  of  Washington,  whom  I  had  seen  use 
Wurtzer's  instrument,  in  the  penitentiary  at  Nashville,  Tenn.,  in 
the  winter  of  1858  and  1859.  He  used  it  in  eight  cases,  with  four 
cures  and  four  relieved  in  part ;  no  deaths ;  all  were  wearing 
trusses  when  we  saw  them.     When   I  left  Nashville,  I  bought 


GENEEAL   REMARKS   ON   AUTHORS   METHOD.  57 

his  instrument,  and  have  it  yet.     He  did  not  deign  to  answer  my 
letter,  though  I  had  his  name  on  an  ad  eundem  diploma. 

In  1860  I  received  a  letter  from  Dr.  Middeton  Mechell,  of 
Charleston,  South  Carolina,  who  wrote  to  me  for  statistics  of  Wurt- 
zer's  operation  and  other  improvements  in  instruments  for  the  radi- 
cal cure  of  hernia,  saying  he  had  learned  from  Messrs.  George  Tie- 
mann  &  Co.  that  I  had  made  some  instruments.  I  replied  promptly, 
and  stated  I  believed  all  cases  could  be  thus  cured,  as  it  fulfilled 
every  indication,  restoring  the  natural  supports  of  the  abdomen, 
leaving  no  plug  to  be  pushed  out,  and  making  a  clean  seam  in  the 
peritoneum,  as  seen  in  Plate  v,  where  the  peritoneal  flap  is  turned 
down  to  show  the  wires  in  their  position  in  the  peritoneal  cavity. 
Like  Professor  May,  he  did  not  deign  to  reply. 

In  this  letter  to  Dr.  Mechell,  I  stated  I  believed  the  wires  might 
be  put  in  with  a  curved  needle  with  an  eye  in  its  point,  like  a  horse- 
collar-maker's  needle ;  that  it  might  be  threaded  and  pulled  back. 
This  needle  was  like  Dr.  John  Wood's,  made  before  his  book  was 
published,  but  when  I  tried  it,  I  found  it  did  not  work  any  better 
than  the  old  surgeon's  needle ;  it  had  a  handle,  which  made  it 
more  easy  of  insertion. 

The  Civil  War  came  on,  and  Dr.  Mechell's  manuscripts  were 
burned  up ;  the  blockade  was  established,  and  I  could  not  get  any 
more  instruments  made  at  Messrs.  Tiemann  &  Co.'s,  and  we  did  not 
have  any  makers  South,  so  I  did  nothing  more  until  1866,  when 
I  visited  New  York,  in  June,  and  had  Messrs.  Tiemann  &  Co.  make 
a  needle  of  the  present  shape.  They  made  me  some  electrotypes  of 
the  needle,  and  cuts  showing  my  then  proposed  plan  of  operating, 
and  I  gave  them  a  written  description  of  the  process,  to  be  published, 
with  the  cuts,  in  the  New  York  Medical  Record,  then  to  be  sent  to 
me  at  Galveston,  Texas,  which  was  then  and  is  now  my  home. 
This  paper,  with  the  wood-cuts,  appeared  in  the  15th  of  September 
number,  1866. 

Before  I  got  any  case  to  operate  on  with  my  needle,  or  an  oppor- 
tunity to  insert  the  cuts  in  my  journal  [Galveston  Medical  Journal), 
my  office  was  burned,  and  my  needles  and  electrotypes  were  lost,  But> 
I  had  prepared  an  article  on  hernia  for  my  journal,  and  published  it  in 
the  November  and  December  numbers  of  1866,  from  which  I  have 
taken  most  of  the  above  report,  and  which  may  be  consulted,  for 
further  particulars.  I  sent  again  to  New  York  for  my  needle, 
and  got  Wood's,  of  London,  with  which  I  tried  to  perform  my 
5 


58  HERNIA. 

operation  on  the  dead  subject,  but  failed,  as  above  stated,  to  do  it 
to  my  satisfaction,  I  wrote  again,  and  referred  to  the  cuts,  and 
sent  a  pen  draft  of  the  needle  wanted,  and  in  due  time  they  came. 

Case  5. — Josiah  Overton,  sailor,  age  thirty  years,  had  inguinal 
direct  hernia  of  left  sh'e,  about  the  size  of  a  man's  fist.  Had  been 
operated  on  with  Wurtzer's  instrument  in  Calcutta,  but  the  hernia 
returned,  and  he  came  to  the  City  Hospital  (then  under  my  charge), 
for  strangulated  hernia.  It  being  reduced,  and  the  tenderness 
passing  off,  I  proposed  to  cure  him  by  my  process,  to  which  he 
consented,  and  the  following  is  the  report,  made  by  Dr.  C.  H. 
Wilkerson,  then  a  second  course  student  and  resident  in  the  hospi- 
tal.    See  page  745,  June,  1867. 

''Josiah  Overton,  aged  24  years;  an  Englishman;  seaman  on 
the  schooner,  'Wide  World;'  was  admitted  into  City  Hospital, 
May  8th,  for  treatment  of  reducible  oblique-inguinal  hernia  of 
the  right  side.  He  had  been  treated  for  it  with  Wurtzer's  instru- 
ment, in  Calcutta,  about  nine  months  before;  it  had  returned 
several  days  before  admission,  as  bad  as  ever.  There  were  scars 
of  the  needle  at  two  points,  but  no  indentation  about  the  opening 
of  the  internal  or  external  ring,  but  there  was  a  thickening 
around  the  scar  in  the  scrotum.  Prof.  Dowell  determined  to 
operate  after  his  own  plan,  with  the  consent  of  the  patient.  He 
performed  the  operation  on  the  10th  of  May,  assisted  by  Drs. 
Hanna,  Barnet,  and  myself. 

"The  operation  was  performed  in  the  following  manner: — The 
double  spear-pointed  curved  needle  was  threaded  with  silver  wire 
at  one  end,  and  the  threaded  end  was  taken  in  the  right  hand,  and 
a  portion  of  the  skin  and  cellular  tissue  pinched  up  with  the  left 
hand  fingers  over  the  rupture,  and  the  needle  inserted  from  left  to 
right,  and  then  pulled  through  until  the  threaded  point  reached 
the  body  of  the  tendons  on  the  right  side,  when  the  sac  was  invagi- 
nated  and  the  threaded  point  pushed  through  the  side  of  the  right 
tendon  and  passed  across  the  opening  to  the  left  tendon  and  out  on 
the  left  side;  then  the  needle  was  drawn  until  the  unthreaded 
point  passed  the  external  side  of  the  tendons,  and  then  reversed  and 
pushed  through  the  skin  beyond  where  it  was  first  inserted.  A 
second  ligature  was  applied  in  the  same  manner,  and  both  tied  over 
a  piece  of  cork,  drawing  the  edges  of  the  two  tendons  together,  as  de- 
scribed in  the  December  number  of  the  Galveston  Medical  Journal 
and  in  the  New  York  Medical  Record,  of  September  15tli,  1866. 


OPERATIONS  BY  AUTHOR's  METHOD.  59 

"  May  lOtli. — Evinced  peritoneal  symptoms. 

"14tli. — Pain  more  contracted;  is  entirely  confined  to  neighbor- 
hood of  operation. 

''  15th. — Sutures  withdrawn  and  cold  fomentations  applied. 

"20th. — Pus  has  been  forming  and  oozing  through  the  apertures 
since  the  withdrawal  of  the  sutures. 

"24th. — Diminished  excretion,  gradual  reduction  of  swelling, 
and  subsidence  of  pain  since  20th. 

"  28th. — Patient  is  rapidly  improving ;  is  cheerful  and  easy ;  says 
he  can  cough  and  sneeze  without  the  return  of  his  complaint,  which 
he  could  not  do  before  the  operation. 

"June  3d. — Is  walking  about,  quite  well ;  says  the  operation  and 
treatment  were  not  so  bad,  nor  so  painful,  as  the  former;  says  he  is 
all  right  now. 

"  Cart  H.  Wilkerson,  House  Surgeon" 

Case  6. — Mr.  W.  R.  J.,  aged  twenty  years,  a  clerk,  native  of 
Galveston,  grandson  of  N.  M.  and  nephew  of  Commodore  M. 
Hernia  on  left  side,  oblique-inguinal,  of  several  years'  standing. 
This  patient  suffered  also  from  congenital  strabismus,  and  the 
hernia  was  no  doubt  of  the  variety  I  have  called  hernia  tunica 
corda  propria  testis,  usually  called  infantile,  or  encysted. 

The  operation  was  performed  in  the  winter  of  1869-70,  in  the 
presence  of  Prof.  Webb  and  a  portion  of  the  medical  class  of  that 
session.  Two  ligatures  were  used,  and  the  wires  were  taken  out  on 
the  tenth  day.  Some  suppuration  along  the  lines  of  the  wire,  but 
only  in  those  sides  where  the  skin  and  cellular  tissue  were  inclosed 
in  turning  the  needle.  No  symptoms  of  peritonitis.  No  fever  of 
any  kind,  and  very  little  pain,  and  that  mostly  produced  by  flatu- 
lency, the  result  of  taking  morphine  to  keep  the  bowels  quiet.  Lead 
and  laudanum  solution  was  used  as  before.  The  bowels  were 
moved  before  cutting  the  wires,  on  the  tenth  day,  and  only  one 
wire  was  taken  out ;  the  other  was  cut,  but  left  in,  as  there  was 
some  puckering  on  one  of  the  sides.  This  wire  was  pulled  out  by 
being  caught  in  the  blankets  of  the  bed ;  it  was  believed  by  the 
patient  to  have  buried  itself  under  the  skin.  After  getting  well 
and  free  from  all  suppuration,  he  came  to  my  office,  saying,  it  was 
buried,  and  he  wanted  me  to  take  it  out.  He  said  he  could  feel 
it,  and  I  examined  it,  but  could  not  feel  any  wire.  I  thought 
it  must  be  there,  as  there  was  some  tightness  and  a  band  in  the 
line  he  complained  of,  but  not  finding  it,  I  put  him  under  chlo- 


60  HERNIA. 

roform  in  my  office,  and  cut  througli  the  skin,  but  failed  to  find 
it.  I  then  cut  down  to  the  band,  and  still  did  not  find  it.  I  con- 
tinued my  incision  down  to  the  spermatic  cord,  still  not  find- 
ing it.  The  hernia  came  down  as  before,  and  I  closed  the  wound 
with  silver  wire,  interruptured  suture,  putting  the  wires  deep  down 
to  the  sac,  which  was  not  opened.  Let  the  patient  up  from  chloro- 
form and  told  him  what  I  had  done,  and  yet  had  not  found  the 
wire,  and  it  must  have  come  out.  I  sent  him  home,  and  in  a  day 
or  two  he  found  the  wire  stuck  in  one  of  his  blankets.  The  sutures 
were  taken  out  on  the  eighth  day,  but  patient  was  directed  to  keep 
in  bed  for  thirty  days,  and  I  then  put  on  a  well-fitting  truss.  In 
April,  1872,  he  came  to  my  office  to  consult  me  about  a  new  elastic 
truss  (House's)  he  had  just  gotten,  and  asked  my  advice  about  its 
efifects,  as  it  had  no  spring.  I  examined  him  and  found  the  opening 
entirely  closed ;  could  not  insert  my  finger  at  any  point,  and  I  told 
him  he  was  entirely  cured.  He  then  said  he  had  several  times 
forgotten  his  truss  and  went  days  without  it,  and  the  hernia  had 
not  returned. 

This  case  was,  no  doubt,  a  perfect  cure  at  the  first ;  but  losing 
the  wire  caused  a  complication  I  would  not  expect  to  meet  with 
again,  for  if  I  left  the  wire  in,  I  would  so  bend  it,  or  tie  it  at  one 
end,  that  it  could  not  get  into  the  abdomen ;  and  even  if  it  did,  I  do 
not  believe  it  would  produce  suppuration,  or  any  inconvenience, 
except  in  wearing  a  truss. 

Case  7. —  Umbilical  Hernia.  Mrs.  Kussell,  Irish  woman,  aged 
35,  was  operated  on  in  St.  Mary's  Hospital,  under  the  care  of 
Dr.  C.  H.  Wilkerson,  my  former  student.  Below  is  his  report  of 
the  case,  published  in  the  Galveston  Medical  Journal,  1870. 

"  Elizabeth  Russell,  aged  35  years,  applied  for  admission  to  St. 
Mary's  Infirmary,  Aug.  20th,  1869,  to  be  treated  for  an  enlarge- 
ment over  the  umbilical  region,  which,  she  said,  had  existed  for  the 
past  two  years. 

"  The  tumor,  she  added,  was  caused  by  straining  at  lifting,  ap- 
peared suddenly,  gave  great  pain  at  the  time,  and  now  gives  rise 
occasionally  to  a  great  deal  of  suffering  ^  increases  and  diminishes 
in  size  alternately,  being  as  large  as  an  orange  at  times,  but  often 
remains  the  size  of  a  pullet's  egg. 

"  On  inspection  an  umbilical  hernia  presented  itself;  the  tumor, 
about  the  size  of  a  walnut,  occupying  the  space  belonging  properly 
to  the  umbilicus  itself. 


OPEEATIONS  BY  AUTHOH's  METHOD.  61 

''The  tumor,  evidently,  contained  only  mesentery.  This  rup- 
ture not  only  gave  her  constant  uneasiness,  but  often  severe  pain, 
and  prevented  any  attempt  at  work  or  even  exercise.  Having 
applied  collodion,  tannin,  bandages  and  a  truss,  to  no  avail,  it  was 
decided  to  operate  upon  her  for  a  radical  cure :  accordingly,  on  the 
24th  of  August,  the  patient  having  been  gently  purged  by  way  of 
introduction,  she  was  placed  under  chloroform  by  myself,  and  oper- 
ated on  by  Prof.  Dowell,  after  a  method  of  his  own  invention,  viz., 
the  subcutaneous  suture. 

Operation. — The  hernia  having  been  reduced,  a  long  curved 
needle,  double-eyed,  double-pointed,  and  armed  at  one  extremity 
with  silver  wire,  was  thrust  down  through  the  centre  and  brought 
out  below,  at  the  base  of  the  umbilical  tumor.  This  suture  in- 
cluded integument  and  cellular  tissue  only.  Without  reversing  the 
needle  or  clipping  the  wire,  it  was  immediately  passed  back  through 
the  entire  base  of  the  tumor  to  the  opposite  side,  going  deep,  and 
taking  up  in  its  course  through  this  structure  integument,  cellular 
tissue,  the  split  borders  of  the  recti  muscles,  and  passing  down  to  the 
peritoneal  surface. 

"  Again,  without  reversing  the  needle,  it  was  passed  back  through 
the  tumor,  this  time  seeking  the  summit  of  the  enlargement,  where 
it  was  originally  introduced,  and  embracing  in  its  passage  skin  and 
connective  tissue  only.  This  constituted  one  stitch,  although  six 
perforations  with  the  needle  had  been  made.  The  aperture  of  exit 
was  directly  where  the  primary  entrance  had  been  made,  the  ends 
of  the  wire  meeting  at  the  summit  of  the  tumor. 

"  Another  stitch  was  then  taken,  crossing  the  first  at  right  an- 
gles, and  the  extremities  of  the  wires,  having  been  drawn  firmly 
together,  were  tied  down  over  a  small  piece  of  cork,  and  the  pa- 
tient left  to  recover  from  the  efi"ects  of  chloroform. 

Besult. — Aug.  25.  Patient  passed  a  moderately  quiet  night, 
but  only  through  the  agency  of  morphia.  Feels  easy  this  morning, 
but  drowsy  from  opiates. 

"  26th. — Better  and  livelier  to-day ;  appetite  returning ;  tongue 
coated  with  a  white  fur.     Collodion  applied  to  the  parts. 

"  27th. — Redness,  soreness,  and  some  swelling  around  the  um- 
bilicus.    Ordered  lead  water  and  laudanum  fomentation. 

"  28th  and  29th. — Symptoms  much  the  same. 

*'  30th. — Redness  and  swelling  going  down ;  remedies  kept  up. 

"  31st. — Nothing  but  soreness  from  the  sutures  remains,  these 


62  HEENIA. 

having  been  taken  away  on  the  28tli.     Says  she  feels  well  with 
that  exception. 

"  Sept.  10th. — Patient  discharged,  well  and  sound ;  has  walked 
all  about  town  and  yet  no  return  of  tumor.  Only  a  little  soreness 
remains,  the  effect  of  the  sutures,  an  argument,  probably,  in  favor 
of  the  success  of  the  operation." 

It  will  be  noticed  that  the  wires  were  taken  out  on  the  fifth  day, 
and  that  this  was  of  the  variety  of  umbilico-epiplocele,  which  is 
common  in  females  of  adult  age.  I  believe  this  is  the  first  case 
on  record  of  an  umbilical  hernia  cured  by  an  operation  in  the  adult. 

Case  8. — French  sailor,  aged  thirty  years ;  native  of  France ; 
was  a  great  stammerer  from  youth,  showing  congenital  defects. 
He  was  operated  on  in  St.  Mary's  Hospital,  Catholic,  under  Dr.  0. 
H.  Wilkerson,  who  did  not  reside  in  the  institution.  The  patient's 
bowels  were  moved  with  castor  oil  in  the  morning,  the  parts 
shaved,  and  the  patient  put  under  chloroform,  making  three 
lines,  as  usual,  with  tincture  of  iodine  or  ink.  The  hernia  being  on 
the  right  side,  we  put  the  needle  through  in  the  first  position,  to 
the  ventral  side,  which  we  found  to  be  of  great  disadvantage,  hence 
the  direction  given  in  the  process  and  method  now  practiced,  of 
commencing  by  putting  in  the  needle  in  the  first  position  from  the 
ventral  surface,  and  carrying  it  down  inside  of  the  ilio-pubic  liga- 
ment, to  avoid  inclosing  this  tendon  in  the  second  position  of  the 
needle.  In  this  case  we  did  inclose  the  ligament,  and  the  opening 
did  not  come  well  up,  and  when  the  wires  were  taken  out,  on  the 
fifteenth  day,  there  was  considerable  suppuration,  and  several  ab- 
scesses of  small  size  formed.  So  it  was  a  failure,  as  the  hernia 
returned.  After  these  healed  up,  we  operated  again,  with  the  same 
medical  gentlemen  present— Profs.  Eankin,  Allen,  and  the  jnedical 
class  of  1870  and  1871.  The  hgatures  were  kept  in  to  the  twen- 
tieth day,  with  the  same  suppuration  and  result — a  failure. 

We  believe  in  the  first  operation  we  failed  on  account  of  the 
inclosing  of  Poupart's  ligament  (iho-pubic),  and  in  the  last  by 
keeping  the  hgatures  in  too  long ;  we  afterward  avoided  both  these 
accidents  by  our  present  way  of  putting  in  the  wire,  and  by  taking 
it  out  on  the  fifth  or  seventh  day,  and  putting  on  a  support.  The 
one  I  used  was  the  truss  of  a  self-examining  endoscope,  which  an- 
swered the  purpose  very  well.  The  patient  was  unwilling  to  be 
operated  on  again.  He  had  not  sufi"ered  much  pain  under  either 
operation,  but  sufi'ered  from  a  low  typhoid  form  of  fever.     We  do 


OPERATIONS  BY  AUTHOR's  METHOD.  63 

not  think  lie  was  treated  well  after  either  operation,  as  Dr.  "Wilker- 
son  did  not  reside  in  the  institution,  and  we  only  visited  it  every 
Tuesday  and  Friday,  on  clinic  days. 

Case  9. — Mr.  (now  Dr.)  J.  H.  Mayfield,  a  private  student  of 
mine,  age  twenty-two  years ;  small  inguinal  hernia  of  the  left  side. 
Was  operated  on  in  St.  Mary's  Hospital,  June,  1871.  Present, 
Drs.  Booth,  house  surgeon,  and  C.  H.  Wilkerson,  surgeon.  Bowels 
moved  with  castor  oil  in  the  morning  ;  the  parts  were  well  shaved, 
and  three  lines  made  with  ink.  Patient  was  put  under  chloroform, 
and  the  operation  commenced  by  putting  the  needle  through  in 
first  position,  from  the  ventral  side  toward  the  ligament,  and  then 
down  for  second  position  inside  of  Poupart's  ligament.  Two  wires 
were  used,  which  completely  closed  the  opening ;  ligatures  tied 
over  a  piece  of  cork  ;  taken  out  on  eighth  day ;  some  suppuration, 
but  no  symptoms  of  peritonitis,  and  not  much  pain.  After  the 
wires  were  taken  out,  a  compress  and  bandage  were  used  for  about 
thirty  days.  Cure  perfect.  He  was  in  my  office  in  April,  1874, 
still  perfectly  well. 

Case  10. — Dr.  C.  H.  Wilkerson  operated  on  a  French  boy,  about 
twelve  years  old,  assisted  by  Professor  Callaway  and  myself.  I 
directed  him  how  to  hold  the  needle,  and  in  every  step  of  the  opera- 
tion, he  using  my  own  needle,  loaned  him  for  that  purpose. 
The  wires  were  kept  in  for  fourteen  days.  I  did  not  again  see  the 
case,  and  had  nothing  to  do  with  the  after-treatment,  but  it  was  a 
failure,  I  believe  from  keeping  in  the  wires  too  long.  He 
was  operated  on  again,  assisted,  as  before,  by  Prof.  Callaway  and 
myself.  The  wires  were  taken  out  on  the  eighth  day,  and  union 
appeared  perfect.  Dr.  Wilkerson  published  this  case  in  the  Gal- 
veston Medical  Journal  (my  own  journal),  without  mentioning  my 
directing  him,  he  using  my  needle  and  carrying  out  my  entire 
method,  as  if  it  was  an  original  operation  of  his  own,  only  stating 
I  gave  the  chloroform,  claiming  all  the  credit  for  himself.  This 
was  put  in  while  I  was  absent  from  the  city,  which  made  it  much 
worse,  showing  so  little  gratitude  and  complacency  to  his  former 
preceptor.  I  thus  speak  of  the  case,  as  it  was  republished  in  several 
journals,  and  no  mention  made  of  its  being  my  process  and  method, 
Dr.  C.  H.  Wilkerson  claiming  all  the  credit  to  himself.  It  is  due 
him,  to  say  that  his  apology  was,  that  it  was  so  universally  known 
to  be  my  operation  that  he  did  not  think  of  it ;  but  before  I  sub- 
mitted the  manuscript  to  the  printers,  I  put  in  a  note  stating  it 


64  HERNIA. 

was  my  process  and  method  tliat  was  used.  He  or  the  printer  took 
this  out.  The  printer  denied  it.  Ingratitude  has  no  bounds,  and 
if  I  cannot  rely  on  my  own  pupils  to  establish  my  precedence  in 
this  operation,  who  can  I  rely  on?  I  felt  this  more  severely  as 
Drs.  May  and  Mechell  had  treated  me  so  cavalierly.  Dr.  Wilker- 
son  told  me  the  hernia  in  his  patient  had  returned  from  his  lifting 
and  hauling  sand,  about  the  1st  of  April,  1872. 

Case  11. — John  Foster,  aged  about  thirty-two  years,  German 
sailor,  was  admitted  into  the  "  Galveston  Medical  College  Hospi- 
tal," then  under  my  charge,  for  a  wound  of  the  scalp,  resulting  in 
traumatic  erysipelas.  He  recovered  from  this,  and  finding  him 
sufiering  from  a  very  large  scrotal  hernia  of  the  right  side,  we 
proposed  to  cure  him,  and  explaining  the  nature  of  the  operation 
to  him,  he  consented.  He  had  been  operated  on  in  Calcutta,  by 
what  I  supposed  was  either  Gerdy's  or  Wurtzer's  method ;  and  he 
said  it  had  done  him  a  great  deal  of  good,  as  before  that  it  came 
half  down  his  thighs,  and  could  not  be  kept  up  with  a  truss.  The 
hernia  was  as  large  or  larger  than  the  two  fists  together.  He  was 
not  well  prepared,  being  dissipated,  and  was  drunk  when  first 
brought  into  the  hospital.  But  being  anxious  to  be  operated  on, 
and  impatient  to  leave  the  hospital,  we  operated  on  him  February 
18th,  1872.  The  bowels  being  moved  in  the  morning,  chloroform 
being  given — Profs.  Rankin,  Goodwin,  and  the  medical  class  of  1871 
and  1872,  were  present — four  ligatures  were  put  in  and  tied  over 
a  soft  piece  of  wood  wrapped  with  a  roller  bandage.  Patient 
vomited  much  from  the  chloroform,  and  had  hiccough  in  the  first 
twenty-four  hours.  We  moved  his  bowels  with  castor  oil,  to  see  if 
there  was  any  intestinal  obstruction ;  the  bowels  were  freely  moved, 
but  the  hiccough  and  vomiting  continued ;  pain  around  the  umbili- 
cus, with  tenderness  over  the  stomach,  but  little  in  the  line  of  the 
ligatures.  The  hernial  sac  became  distended  to  its  full  size  and 
form,  hot  and  tense,  some  heat  of  skin,  and  pulse  one  hundred  and 
twenty.  Blister  over  the  stomach,  and  morphine  continued,  with 
solutions  of  lead  and  laudanum.  Scrotum  very  tense  on  the  fifth 
and  sixth  days,  oedematous,  and  crackling  with  gas.  Exploring 
needle  used  on  the  sixth  day ;  serum  and  blood  came  out.  The  part 
was  freely  lanced,  and  the  bowels  moved  on  the  seventh  day,  and 
the  ligatures  taken  out  after  the  action  on  the  bowels.  The  line  of 
the  ligatures  perfectly  tight;  no  fluid  could  pass  into  the  peritoneum. 
Fever  continued ;  testicles  and  scrotum  poulticed,  and  morphine 


OPEEATIONS  BY  AUTHOR's  METHOD.  65 

internally ;  continued  to  vomit  what  lie  drank,  but  no  stercoraceous 
matter.  Would  get  up  in  the  night  and  empty  his  own  chamber 
mug ;  pain  and  swelling  in  sac  continued  to  increase,  and  finally, 
there  being  perceptible  fluctuation,  an  abscess  was  lanced,  which 
discharged  about  half  a  pint  of  sanious  pus,  but  with  no  fecal 
odor.  The  poultices  were  continued,  and  another  abscess  was 
finally  lanced,  discharging  a  large  amount  of  pus,  as  before.  After 
this  he  continued  to  improve  rapidly,  his  vomiting  ceased,  and  his 
appetite  returned.  He  got  drunk  twice,  and  fell  eight  feet  down  a 
a  ladder,  without  the  hernia  returning.  He  continued  in  the  hos- 
pital, assisting  the  cook,  till  the  15th  of  April.  The  endoscope  truss 
was  then  taken  oS",  and  a  good-fitting  truss  applied.  Hernia  line 
very  firm  and  no  tendency  to  return.  He  left  for  New  York,  on  a 
steamer,  on  the  15th  of  April.  This  was  the  only  case  attended  with 
any  serious  symptoms,  most  of  them  suffering  but  little  pain  or  swell- 
ing of  the  parts,  and  only  three  any  symptoms  of  peritonitis ;  in  two, 
this  only  lasted  about  twenty-four  hours,  as  was  seen  in  the  full 
report  of  the  cases.  No  deaths,  and  only  one  complete  failure  in 
eight  cases  operated  on  by  myself  after  I  got  the  present  needle. 
Dr.  Wilkerson's  case  being  apparently  a  success,  but  at  last  report 
had  returned. 

Four  cases  of  strangulated  hernia  were  cured  by  the  interrupted 
suture,  with  the  semicircular  double-spear-point  needle,  as  will  be 
seen  further  on,  under  strangulated  inguinal  and  scrotal  hernia. 

The  following  cases,  which  have  all  occurred  since  April,  are 
reported  as  examples  of  the  whole  : — 

Case  12,  partial  failure. — P.  B.,  colored  ;  aged  about  39  ;  stout 
a-nd  healthy.  Hernia  right  side,  seventeen  years'  standing  ;  large 
scrotal ;  April  11th,  1876. 

Operation  for  radical  cure  by  our  plan  of  subcutaneous  sutures 
with  silver  wire.  Patient  put  under  chloroform  by  Dr.  Orman 
Knox,  of  Jonesville,  Texas.  We  reduced  the  hernia  ;  then  having 
made  three  lines,  one  over  centre  of  tumor,  and  one  on  each  side, 
about  half  an  inch  from  the  centre,  four  stitches  were  put  in,  one 
below  the  other.  This  was  a  bad  case  for  the  operation,  as  the 
tendons  were  severed  above  the  ileo-pubic  ligament  for  two  inches, 
and  the  hernia  was  direct  at  the  line  of  the  operation,  but  proba- 
bly had  become  so  by  long  standing,  as  the  opening  was  large. 

April  13th. — Doing  well ;  scrotum  slightly  swollen,  but  not  pain- 
ful ;  no  fever. 

April  19th. — No  fever;  scrotum  much  swollen,  but  soft;  liga- 


66  HERNIA. 

tares  removed  ;  cure  appears  perfect ;  bowels  had.  been  moved  yes- 
terday. 

May  SOth. — Saw  patient ;  bowel  had  returned  to  sac  on  the  night 
of  the  24th,  while  in  bed,  he  having  been  ploughing  and  riding. 
The  swelling  of  the  scrotum  had  never  been  reduced,  and  I  ought 
to  have  put  in  a  seton  through  the  sac  or  used  Wurtzer's  needle,  so 
as  to  cause  destruction  of  old  sac.  This  was  neglected  in  this  case, 
and  was  one  cause  of  failure,  but  the  great  distance  to  which  the 
tendons  were  separated  was  the  main  cause ;  in  subjects  as  old 
as  this  man  the.y  can  rarely  be  pulled  together  at  one  operation. 
Applied  a  Pomeroy  truss  and  left  him  at  work  and  comfortable.  I 
will  operate  again  in  October. 

Case  13. — April  19th,  1876,  H.  S.,  aged  69  ;  knock-kneed  from 
a  boy ;  ruptured  on  left  side ;  very  large  scrotal.  He  suffered 
eighteen  years  ago  with  strangulation,  and  was  operated  on  by  Drs. 
Orman  Knox  and  H.  P.  Perry ;  recovered,  and  was  cured  for  one 
or  two  years.  .Ever  since  it  has  been  getting  larger,  until  now  it 
is  as  large  as  a  boy's  head.  Assisted  by  Dr.  Knox,  who  gave  chlo- 
roform, I  operated  by  the  "  subcutaneous  suture."  Pbcducing  the 
hernia,  we  put  in  four  stitches,  one  below  the  other,  about  one  inch 
apart,  and  pulled  the  parts  well  together,  overlapping  the  tendons. 

21st. — Doing  well;  no  fever;  ordered  the  bowels  to  be  moved 
with  Epsom  salts. 

27th. — Stitches  taken  out ;  had  not  had  any  fever  ;  bowels  had 
been  moved;  scrotum  tender,  but  very  little  more  swollen. than  at 
time  of  operation.  Operation  a  cure.  Dr.  Knox  writes  me,  June 
25th,  "  S.  S.  a  perfect  cure."  August  28th. — "  Tumor  decreasing, 
still  perfectly  cured." 

Case  14. — J.  B.,  aged  7 ;  healthy  ;  hernia,  scrotal,  left  side, 
three  years'  standing,  supposed  to  be  caused  by  having  had  a  rope 
tied  around  the  body.  Dr.  Knox  gave  chloroform.  One  ligature 
completely  closed  up  the  opening. 

25th. — Up,  walking  about ;  no  fever ;  very  little  swelling  of 
scrotum,  a  little  red. 

28th. — Li2;ature  taken  out. 

I  was  taken  very  sick  about  this  time,  with  bilious  fever,  and  did 
not  see  him  any  more  until  May  20th.  Upon  examination,  found 
a  swelling  of  the  cord ;  pronounced  it  hydrocele  of  the  cord,  and 
stated  that  it  would  require  a  second  operation. 

May  26th. — Operated  on  the  cord,  putting  in  three  ligatures, 
one  below  the  other. 


OPERATIONS  BY  AUTHOR'S  METHOD.  67 

28tli. — Testicle  miicli  swollen  ;  old  sac  enlarged ;  no  fever. 
Gave  him  one-eighth  of  a  grain  of  morphine,  to  keep  him  easy  and 
make  him  sleep.  No  fever ;  walking  around  the  room,  and  even 
out  in  the  yard  ;  has  good  appetite.  I  left  next  day  for  Philadel- 
phia. Dr.  Knox  writes,  June  25th,  "  J.  B.  perfect  success  ;"  family 
much  pleased.  August  28th. — "  Scrotum  filled  with  serum,  but 
no  protrusion." 

Case  15.— May  26th,  1876,  I.  I.  P.,  aged  28 ;  native  of  South 
Carolina ;  hernia  testalic,  right  side ;  no  scrotum  on  that  side ; 
testicle  lodged  in  superior  ring ;  swells  and  gives  great  pain,  especi- 
ally when  he  lifts  or  rides  much ;  was  much  swollen  yesterday. 
Dr.  Knox  gave  chloroform.  Present,  patient's  father  and  others. 
Mr.  P  said  his  son  had  been  born  with  no  scrotum  on  that  side, 
and  that  the  testicle  had  not  come  out  more  than  we  then  saw. 

Operation. — Testicle  pushed  up  and  back  ;  four  ligatures  put  in 
subcutaneously,  one  below  the  other — I  say  below,  as  the  upper 
stitch  must  always  (in  this  method)  be  put  in  first — making 
one  line  in  centre  and  two  on  each  side  ;  having  moved  the  bowels 
well,  as  is  my  custom,  and  also  moving  them  before  taking  out  the 
stitches,  giving  morphine  whenever  patient  is  in  pain,  and  applying 
cold  lead  and  laudanum  water  when  it  is  soothing  and  pleasant. 
After  putting  in  the  ligatures  we  put  lint  over  them,  and  poured 
collodion  over  this,  which  excluded  the  air,  and  compressed  the 
parts.  I  also  directed  Dr.  Knox,  when  they  cut  the  wires,  to  put 
on  lint,  and  pour  on  collodion. 

May  28th, — Had  to  take  some  morphine  to  keep  easy  ;  no  fever ; 
bowels  ordered  to  be  moVed  with  Epsom  salts.  Dr.  Knox  writes, 
June  25,  "  Mr.  P.  well ;  walking  about."     August  28. — "  Is  well." 

The  following  is  a  table  of  all  the  cases  operated  on,  and  their 
results  up  to  date,  September  12th,  1876  :  — 

STATISTICAL    RESULTS. 

OPERATORS.  NO.   OF  CASES.  CURES.  FAIIiXmES. 

Dowell 68  60                          8 

WilkersoD 12  7                          5    ' 

Bacon 1  1 

Trueheart 9  6                           3 

Powell 2  2 

Raukin 1  1 

Worthington 1  1 

Neesou 1  1 

Worthington  &  Bibb 1  1 

Totals 96  80 


68  HERNIA. 

In  the  sixty-eight  cases  operated  on  by  myself,  two  were  umbili- 
cal, one  epigastric,  one  testicalic,  and  the  others  were  femoral, 
inguinal  and  scrotal.  From  one  to  five  sutures  were  used.  In 
one  case  only  has  there  been  any  serious  trouble,  and  that  was 
caused  from  suppuration.  The  longest  time  any  one  was  confined  in 
bed  was  thirty  days;  the  shortest,  twenty-four  hours.  One  case 
was  operated  on  twice;  failure  both  times.  Dr.  Wilkerson  ope- 
rated twice  on  two  cases.*  Dr.  Trueheart's  failure  was  in  a  case 
of  double  hernia.  Dr.  Powell  operated  twice  on  one  case.  No 
deaths  have  occurred  from  the  operation.  Dr.  Rankin  published 
his  case  in  full  in  the  Texas  Medical  Journal. 

The  other  cases  of  failure  by  me,  one  (Mr.  Holt)  was  caused  by 
obesity  and  bilious  vomiting.  Another  (Mr.  Kirtland)  from  no 
known  cause ;  believed  we  did  not  go  deep  enough  to  include  the 
sac.  Mr.  Hubbard's  rupture  returned  from  vomiting.  The  eighth 
I  have  not  seen  since  operated  on,  but  learn  it  was  a  failure. 

The  above  tabular  statement  exhibits  all  the  cases,  with  results, 
that  have  been  reported  to  me.  In  concluding  this  paper,  I  can 
truthfully  say  that  no  operation  of  so  great  import  has  ever  been 
attended  with  better  results. 

The  details  of  these  cases  must  have  wearied  the  reader ;  but 
we  thought  they  were  all  necessary  to  the  illustration  of  the  differ- 
ent steps,  as  they  show  the  difficulties  that  have  to  be  overcome ; 
from  which  we  deduce  the  following  principles,  to  be  adopted  and 
carried  out  in  this  operation. 

1.  Points  that  should  he  specially  attended  to  in  the  operation. 

A.  The  bowels  should  always  be  moved  three  hours  before  the 
operation. 

B.  The  body  should  always  be  in  a  horizontal  position,  with  the 
hips  above  the  head,  and  legs  slightly  flexed  on  the  thighs. 

C.  Hernia  should  be  carefully  reduced. 

D.  Patient  should  be  thoroughly  anaesthetized  with  ether  or 
chloroform ;  I  prefer  chloroform. 

E.  Needle  should  be  started  from  the  ventral  or  median  side,  in 
all  cases  of  inguinal  hernia.  Wires  should  be  pulled  in  with  waxed 
thread,  as  in  vesico-vaginal  fistula. 

F.  Wires  should  not  be  left  in  longer  than  the  eighth  day,  and 
a  support  used  afterward,  either  by  truss  or  bandage,  and  patient 
kept  in  bed  for  ten  days,  at  least,  after  the  wires  are  taken  out, 

•  He  detailed  nine  cases  in  the  Texas  Medical  Journal. 


IMPORTANT  POINTS   IN   OPERATION.  69 

and  not  allowed  to  get  up  without  an  abdominal  support.  One  pa- 
tient, Thomas  Nelson,  16  years  of  age,  remained  in  bed  only  one 
night,  and  on  the  eighth  day,  before  the  wires  were  taken  out,  was 
at  the  railroad  depot,  walking  around  as  if  nothing  had  happened. 
Children  never  complain,  and  all  have  been  cured. 

G.  From  a  quarter  to  half  an  inch  of  the  sides  of  the  orifice 
should  always  be  included  in  the  wire. 

S.  Bowels  should  always  be  moved  before  the  wires  are  taken 
out,  with  enemas  of  water  and  soap  (soapsuds),  or  water  and  cas- 
tor oil. 

2.  Points  to  he  especially  avoided. 

A.  The  spermatic  cord  must  be  kept  downward  and  not  inclosed 
in  the  ligature. 

B.  No  immovable  part,  as  the  ilio-pubic  ligament,  should  be  in- 
closed. 

C.  The  adjacent  arteries  and  nerves  should  be  avoided,  if  possi- 
ble, in  crural  and  inguinal  hernia. 

D.  The  ligature  should  always  be  tight  on  both  sides,  showing 
that  the  tendons  are  well  included. 

E.  No  plug  must  be  left  in  the  loop  of  the  ligatures,  to  be 
pressed  into  the  rupture,  thereby  preventing  the  serous  walls  from 
firmly  uniting. 

F.  The  needle  should  have  free  play  in  passing  across  the  orifice 
internally,  so  as  to  be  sure  that  no  omentum  or  intestine  is  caught 
by  its  point  and  transfixed. 

G.  Patient  should  not  be  allowed  to  get  out  of  bed  while  the 
wires  are  in,  nor  for  five  or  six  days  after  they  are  taken  out, 
though  some  have  walked  around  after  the  first  day  without  any 
injury  or  inconvenience. 

H.  There  should  be  no  puckering  on  the  right  or  left  side  of  the 
first  puncture. 

/.  Patient  should  not  be  allowed  any  very  solid  food,  or  very 
rich  diet  while  under  treatment — milk  and  soups  are  best. 

By  observing  the  above  rules  all  cases  may  he  cured,  as  they  en- 
able the  operator  to  restore  the  natural  supports  of  the  abdominal 
wall,  even  where  there  never  were  any.  There  is  no  exposure  of 
the  peritoneum  to  the  air ;  no  plug  placed  in  to  be  pushed  out ;  no 
injection  or  scarification  necessary  to  produce  adhesive  inflamma- 
tion, gentle  pressure  being  quite  sufficient  to  unite  serous  mem- 
branes, as  every  one  knows  who  has  operated    for  strangulated 


70  HEENIA. 

hernia,  remembering  how  firm  the  stricture  becomes  in  four  days — 
so  firmly  united  as  to  tear  rather  than  separate. 

We  thus  close  our  remarks  on  the  radical  cure  of  hernia,  giving 
about  all  that  is  known  on  the  subject,  believing  there  will  never 
be  a  better  method  invented  than  the  Author's  ;  but  of  this  we  are 
not  sure,  as  we  have  seen,  in  our  day,  so  many  improvements  made 
on  what  was  once  thought  perfect. 

IRREDUCIBLE   HERNIA. 

I  think  this  is  a  very  unusual  form  of  hernia,  as  in  my  long 
experience  I  do  not  remember  seeing  a  single  case,  but  Gross, 
Gant,  Ashhurst,  and  nearly  all  writers  on  hernia  give  examples, 
and  we  give  below  a  remarkable  case  from  Dr.  Prince's  Orthopaedic 
Surgery.  The  symptoms  are  well  marked  and  cannot  be  easily 
mistaken.  Generally  the  tumor  is  large  in  size,  and  belongs  to 
inguinal,  scrotal,  umbilical,  csecal,  vesical,  or  ventral  varieties. 
Hernia  of  the  caecum  and  bladder,  from  their  anatomical  charac- 
ters, being  without  peritoneum,  are  usually  irreducible ;  contents 
usually  mixed,  omentum  and  intestine,  but  this  is  not  invariably  the 
case.  Patients  suifer  much  from  dyspepsia,  flatulency,  borborygmi, 
and  colic.  Tumor  may  be  lessened  by  an  effort  at  taxis,  but  can- 
not be  reduced.  Bowels  are  not  compressed  so  as  to  prevent  the 
alvine  evacuations.  Irreducible  hernias  are  very  liable  to  become 
inflamed  and  impacted,  and  also  readily  converted  into  strangu- 
lated. 

Cause. — Irreducible  hernia  is  usually  produced  by  adhesion  of 
its  contents  to  the  sac,  contraction  of  the  neck  of  the  sac,  enlarge- 
ment of  contents  after  protrusion,  as  in  the  omental  and  visceral 
varieties,  so  that  they  cannot  be  pushed  back  and  remain  without 
constriction. 

Prognosis  is  always  unfavorable  in  these  cases,  as  the  patient's 
life  is  constantly  in  danger  from  inflammation,  impaction,  and 
strangulation. 

Treatment — Palliative  and  Curative. — The  Palliative  treatment' 
consists  of  a  well-fitting  bag  truss,  to  keep  the  tumor  of  the  same 
size,  and  to  prevent  a  downward  dragging  and  extension  of  the  sac. 
Dr.  Riggs,  of  New  York,  makes  the  best  I  have  seen.  The  bag 
should  be  made  of  strong  duck  or  leather,  and  should  be  confined 
by  elastic  belts  or  springs  around  the  body.  When  it  is  scrotal  or 
ventral,  of  large  size,  it  must  be  retained  in  a  bag,  and  kept  up  by 


lEEEDUCIBLE   HERNIA.  71 

bands  around  the  body,  to  completely  prevent  its  downward  pres- 
sure. 

Curative  Treatment. — This  consists  in  complete  rest  in  the  hori- 
zontal position ;  the  use  of  mercurials  and  alteratives  to  reduce 
the  tumor  so  it  can  be  returned  ;  complete  relaxation  of  the  neck 
by  sedatives  and  anodynes,  as  opium,  chloroform,  belladonna,  and 
veratrum.  An  ointment  of  belladonna,  veratria,  and  iodide  of  mer- 
cury may,  for  a  time,  be  used  over  the  tumor,  with  the  view  of  pro- 
ducing absorption  and  relaxation.  Patient  should  not  let  himself 
become  constipated  or  the  hernia  impacted  by  cherry,  watermelon, 
or  other  seeds,  which  are  often  the  cause  of  strangulation.  The 
tumor  should  be  kept  immediately  over  the  mouth  of  the  sac,  and 
the  attachments  to  the  sac  are  sometimes  removed  by  a  subcutaneous 
incision  with  a  tenotomy  knife.  A  small  opening  being  made 
through  the  skin  and  fascia,  the  constricted  portion  is  found  and 
the  part  cut.  The  knife  is  guided  by  the  finger  oV  a  grooved 
director,  or  what  is  perhaps  better,  a  broad  director.  The  sac 
should  not  be  opened,  as  there  would  be  great  danger  of  wounding 
the  intestine.  After  the  strictured  sac  is  cut  the  hernia  may  return 
with  its  coverings,  which  is  very  dangerous,  hence  this  is  a  bold 
and  unusual  practice. 

Dr.  David  Prince,  in  his  ''  Intestinal  Plastics,"  page  38,  reports  the 
following  singular  case,  and  its  final  cure  :  — 

"  I.  C.  C,  aged  twenty-nine  years,  tall  and  slender  (colored 
clergyman),  entered  my  infirmary,  November  17th,  1868.  He  had 
become,  in  May,  1867,  the  subject  of  inguinal  hernia,  with  the 
symptoms  of  strangulation,  which  continued  twelve  days,  when  a 
distinguished  surgeon  of  Iowa  operated  upon  him,  leaving  the 
patient  with  an  adventitious  anus,  and  the  loop  of  intestine  adherent 
V\rithin  the  scrotum.  Whether  the  incision  of  the  intestine  was 
made  upon  the  supposition  that  there  was  gangrene,  or  whether  it 
was  accidental,  is  not  known.  From  subsequent  examination,  and 
the  well  nourished  condition  of  the  patient,  the  seat  of  hernia 
seemed  probably  to  be  in  the  lower  portion  of  the  small  intestine, 
in  which  the  faeces  passed  from  right  to  left,  and  that  the  opening 
made  by  the  surgeon  was  in  the  ascending  portion  of  the  loop.  It  fol- 
lowed that  all  the /cBces  passed  out  of  the  abdomen  into  the  scrotum, 
and  in  returning  into  the  abdomen  passed  by  the  adventitious  opening 
made  by  the  operator.  Much  of  the  contents  leaked  out,  especially 
when,  in  consequence  of  taking  cathartics,  or  having  a  diarrhcea, 


72  HEENIA. 

they  were  unusually  thin."  The  patient  wore  a  compress  of  his  own, 
that  was  considered  insecure.  The  original  operator  attempted  to 
close  the  orifice  at  four  different  times,  September,  November, 
December,  and  February,  without  success.  "  In  none  of  these  oper- 
ations were  any  attempts  made  to  dissect  up  and  explore  the 
intestinal  protrusion,"  and,  according  to  patient,  the  only  aim  was 
to  close  the  orifice.  "  My  first  examination  was  intended  to  be 
thorough,  but  I  failed  to  detect  the  entrance  of  the  ilium  into  the  ex- 
ternal loop  through  the  ring.  It  was  supposed  that  the  intestinal 
wall  had  so  sloughed  as  to  have  removed  the  partition  wall,  and 
that  an  operation  that  should  sufficiently  dissect  the  intestine  from 
its  adhesion  in  the  canal,  permitting  it  to  be  drawn  into  the  abdo^ 
men,  would  lead  to  a  closure  of  the  orifice.  The  progress  of  the 
operation  revealed  the  mistaken  diagnosis,  and  led  to  a  change  of 
the  plan  of  treatment. 

"  Operation,  November  l^th,  1868. — The  loop  of  intestine  was 
first  dissected  out  of  the  scrotum,  and  the  portion  of  intestine 
protruding  through  the  external  ring  was  cut  off.  It  then  appeared 
that  there  were  two  intestinal  openings  into  the  abdomen,  and  the 
philosophy  of  the  case  was  for  the  first  time  unequivocally  cleared 
up.  A  ligature  was  introduced  through  the  septum,  about  an  inch 
and  a  half  beyond  the  level  of  the  skin ;  each  end  of  the  ligature 
was  passed  through  a  double  canula,  and  made  fast,  and  from  day 
to  day  tightened  up  until  it  cut  through.  The  fear  of  peritoneal 
inflammation  prevented  the  insertion  of  the  ligature  to  such  a 
depth  as  certainly  to  restore  the  permanent  continuity  of  the 
intestinal  canal."  A  good  deal  of  constitutional  fever  followed 
this  operation,  the  patient  being  delirious  for  several  days.  The 
rapidity  of  the  pulse  was  kept  down  by  veratrum  viride,  at  first, 
and  the  powers  afterward  sustained  by  quinine  and  beef-tea. 
Some  sloughing  of  the  scrotum  occurred,  apparently  from  the 
arrest  of  pus  in  the  pocket  from  which  the  intestinal  loop  had 
been  dissected.  The  thread  cut  through  in  a  few  days,  and  the 
external  wound  contracted  rapidly ;  but  upon  careful  examination 
it  was  found  that  the  septum  came  too  near  the  surface  to  make  it 
safe  for  the  integument  to  close,  lest  a  stricture  and  arrest  of 
intestinal  contents  should  be  the  result.  Besides,  it  was  supposed 
that  there  must  have  occurred  adhesion  in  the  septum  or  eperon, 
behind  the  ligature.  This  supposition  is  the  more  probable  as  the 
surfaces,  covered  by  granulations,  pressed  against  each  other,  and 


IRREDUCIBLE   HERNIA.  73 

would  thus  have  the  best  opportunity  to  hook  into  each  other,  and 
thus  effect  a  continuity  of  tissue.  "The  contemplation  of  the 
danger  of  failure  of  adhesion  after  the  introduction  of  the  forceps 
of  Dupuytren,  led  to  the  invention  of  an  apparatus  intended  to 
avoid  gangrene.  For  this  purpose  it  is  necessary  to  avoid  a  tight 
squeeze  upon  any  of  the  tissue.  A  hook  or  tongue  is  made  to  in- 
vaginate  the  intestinal  coats  through  the  ring,  thus  bringing  the 
peritoneal  surfaces  into  close  contact,  but  without  such  force  as  to 
interfere  with  the  circulation.  The  perforation  takes  place  by  a 
gradual  thinning  over  the  point  of  the  instrument,  so  that  the  ori- 
fice is  at  first  small,  and  is  surrounded  by  a  large  extent  of  serous 
surfaces  in  close  contact.  This  differs  entirely,  in  the  principle  of 
its  action,  from  the  instruihent  of  Delpech,  which  cuts  out  a  disk 
by  the  gangrene  occasioned  by  the  pressure  of  two  rings  together, 
involving  more  risk  than  the  forceps  of  Dupuytren,  which  only  cut 
a  fissure.     (See  author's  instrument,  page  17.) 

The  apparatus  (see  Prince's  Orthopaedic  Surgery)  consists  of  — 
aa,  a  loop  or  ring  to  be  introduced  into  one  portion  of  intestine 
through  the  orifice;  hh,  a  perforating  hook  for  the  purpose  of 
making  a  communication  between  two  adjoining  intestinal  tubes. 

The  loop  or  ring  having  been  introduced  through  one  intestinal 
orifice,  and  the  hook  through  the  other,  the  hook  or  male  part  of 
the  apparatus  pushes  a  portion  of  the  doubled  intestinal  wall 
through  the  ring  or  female  portion,  and  slowly  perforates  the  in- 
testine by  ulceration  without  gangrene.  Two  peritoneal  and  two 
mucous  surfaces  are  to  be  perforated  by  a  point  or  hook  invaginating 
them  within  the  circumferences  of  the  ring.  As  there  are  no  sharp 
corners  or  points,  the  process  is  sufficiently  short  to  permit  adhe- 
sion of  the  peritoneal  surfaces.  The  opposite  end  of  the  back  hori- 
zontal portion  of  the  apparatus  has  a  hook  to  hold  an  elastic  cord, 
to  aid  in  the  pressure  of  the  hook  through  the  loop  c ;  the  elastic 
cord  just  mentioned,  a;  a  shield  made  of  tin,  to  serve  as  the  bars  of 
a  hfting  process  to  be  instituted  as  soon  as  the  hook  h  has  fully 
engaged  in  the  loop  a;  ee,  a  derrick  for  the  lifting  process ;  /,  an 
elastic  cord  attached  to  the  combined  arrangement  aa,  hh,  and 
tied  over  the  top  of  the  derrick  ee,  the  lifting  power. 

In  two  weeks  a  passage  seemed  to  have  been  made  from  one  tube 

to  the  other,  through  which  some  of  the  intestinal  contents  passed. 

It  became  necessary  to  apply  a  lifting  force  to  the  hook  and  ring, 

in  order  to  force  them  to  divide  the  bridge  between  them  and  the 

6 


74  HERNIA. 

surface.  For  this  purpose  a  derrick  a,  ee,  f,  was  constructed  with 
a  base  of  tin,  having  an  orifice  in  the  centre,  with  a  loop  of  wire 
about  three  inches  high.  From  the  top  of  this  loop  an  elastic 
cord  /,  was  extended  to  the  wire  apparatus,  constituting  a  hook 
and  eye,  by  which  a  deep  orifice  had  been  made  from  one  portion 
of  the  intestine  to  the  other.  When  the  hook  had  come  very  near 
the  surface,  a  ligature  was  passed  beneath  the  bridge,  and  having 
been  passed  through  the  tubes  of  a  ligating  canula,  it  cuts  through 
in  a  very  short  time. 

After  the  complete  and  ample  restoration  of  the  continuity  of  the 
alimentary  canal,  the  external  orifice  diminished  rapidly,  but  at 
length  it  came  to  a  stand-still.  Finally,  to  close  this,  a  plastic 
operation  was  performed,  Feburary  23,  1869.  This  consisted  in  a 
free  dissection  of  integument  from  above,  by  the  first  variety  of  the 
third  method  of  my  classification.  That  is  by  a  jumping  process. 
The  flap  was  carefully  adapted  to  its  new  position,  and  retained  by 
sutures  of  wire.  Moderate  compression  was  employed  to  prevent 
its  separation  by  the  pressure  of  the  faeces  beneath.  The  surface 
from  which  the  flaps  were  taken  were  left  to  granulate  and  cicatrize. 
Adhesion  was  effected  in  every  part,  and  the  final  cure  was  thus 
secured  after  a  period  of  treatment  of  three  months'  duration.  The 
patient  was  advised  always  to  wear  a  truss  to  protect  the  part  from 
danger  of  a  hernial  protrusion,  from  the  pressure  of  the  intestines 
upon  the  enlarged  ring.  The  removal  of  such  a  horrid  disability 
could  not  fail  to  secure  the  warmest  gratitude  of  the  patient.  *  *  * 
At  this  date.  May,  1871,  the  patient  continues  well,  and  is  travel- 
ing as  an  itinerant  preacher. 

I  have  reported  this  case  nearly  in  the  author's  own  words,  and 
I  do  it  for  two  reasons :  first,  it  shows  what  may  be  done  in  such 
desperate  cases,  and  leads  us  to  hope  that  all  similar  cases  may  be 
cured.  Second,  to  illustrate  a  new  process  for  the  relief  of  artificial 
anus,  of  which  I  will  have  more  to  say  in  treating  of  strangulated 
hernia. 

INFLAMED   HERNIA. 

Hernias  may  become  inflamed,  whether  reducible,  irreducible, 
impacted,  or  strangulated. 

Symptoms. — There  is  more  or  less  soreness  in  the  body  and 
fundus  of  the  sac,  with  heat,  pain  and  swelling,  and  a  large  amount 
of  serum  may  be  effused ;  if  the  hernia  be  loose  and  pendant,  with 


IMPACTED    HERNIA.  75 

niucli  distention  of  the  sac,  sometimes  gas  is  found,  giving  it  a  crepi- 
tative  feel.  The  accumulation  of  serum  makes  the  tumor  more  or 
less  transparent.  It  is  often  attended  with  vomitings  of  indigest- 
ible matter,  bile,  and  mucus,  attended  with  retching,  constipation, 
and  constitutional  fever 

The  hernia  can  most  always  be  reduced  by  the  taxis  judiciously 
applied  under  chloroform,  with  ice  applied  over  the  tumor.  There 
is  scarcely  any  pain  at  the  neck  of  the  sac,  for,  if  that  be  the  case, 
the  inflamed  hernia  has  become,  or  is  about  to  become,  strangulated. 

Causes. — Over-distention  of  the  contents  of  the  sac,  as  from  over- 
feeding, constipation;  accumulation  of  foreign  substances  in  the  sac, 
as  worms,  seeds,  ingesta,  kicks,  falls,  and  blows  on  the  sac. 

Treatment — Is  nearly  the  same  as  that  for  irreducible  hernia. 
Eest,  low  diet,  refrigerant  lotions,  as  ice-water,  and  the  hydrochlo- 
rate  of  ammonia,  sugar  of  lead  and  laudanum,  etc.  The  bowels 
should  be  moved  with  castor  oil  and  turpentine  enemata.  Injections 
of  large  quantities  of  warm  water  with  a  hydraulic  syringe ;  saline 
cathartics,  or  sulphate  of  magnesia,  solution  of  citrate  of  magnesia 
and  mercurials,  where  there  is  constitutional  fever. 

These  means  will  usually  relieve ;  but  when  they  fail,  and  the 
vomiting  continues,  with  stercoraceous  matter,  I  should  at  once 
resort  to  the  knife. 

IMPACTED   HERNIA. 

This  is  another  variety  that  readily  leads  to  strangulation,  and 
should  be  immediately  attended  to. 

Symptoms. — There  is  great  distention  of  the  sac,  not  attended  at 
first  with  much  pain,  and  a  fullness  and  pressure  in  the  tumor. 
This  variety  is  quite  common  in  old  standing  cases  of  reducible 
hernia,  where  the  patient  has  kept  off  the  truss,  or  having  broken 
it,  goes  for  several  days  without  it,  which  enables  the  intestine 
folds  to  fill  with  faeces,  scybillse,  and  indigestible  substances. 
Patients  that  have  suffered  for  years  from  reducible  hernia  become 
entirely  indifferent  to  an  impacted  hernia,  until  it  becomes  inflamed 
and  tender,  and  often  when  they  attempt  to  reduce  it  they  find  it 
strangulated.  The  first  case  I  saw  after  I  commenced  the  study 
of  medicine  was  in  a  doctor,  and  he  seemed  indifferent  to  it,  even 
after  he  found  he  could  not  reduce  it  himself,  as  he  had  often  done 
before.  After  a  delay  of  several  days  in  this  situation,  he  sent  for 
a  surgeon ;  he  failed  to  reduce  it,  and  before  he  would  consent  to  an 


76  HEENIA. 

operation,  lie  was  taken  with  stercoraceous  vomiting,  and  finally 
died,  without  an  operation. 

Impacted  hernias  often  cause  adhesions  of  one  portion  of  an  intes- 
tine to  another,  or  if  the  contents  be  composed  of  intestine  and 
omentum,  the  intestine  becomes  attached  to  the  omentum,  or 
wound  around  it,  and  when  reduced,  these  remain  thus  adhered, 
and  lead  to  a  future  strangulation,  or  a  more  complete  impaction. 
I  have  known  severe  pain  and  colic  to  follow  a  reduced  hernia  of 
this  kind,  and  to  last  for  days,  jeopardizing  the  patient's  life,  and  I 
have  no  doubt,  often  producing  death,  when  the  patient  is  said  to 
have  died  of  colic,  or  invagination ;  it  often  produces  nausea,  and 
vomiting  of  bile,  mucus  and  ingesta,  and  when  fatal,  stercoraceous 
matter,  attended  with  peritonitis  and  emphysema  of  the  intestinal 
canal,  finally  dying,  with  a  cold  clammy  sweat,  attended  with 
hiccough. 

Treatment — Should  be  prompt  and  efficient.  The  contents  pro- 
ducing the  impaction  should  be  gradually  and  carefully  pressed  back. 
Patient  should  remain  in  a  horizontal  position,  completely  relaxing 
the  muscles.  If  there  be  much  serum  in  the  sac,  it  may  be  let  out 
with  a  trocar,  carefully  inserted,  or  if  gas,  it  can  be  discharged  by 
the  exploring  needle.  Patient  should  then,  if  the  hernia  is  not 
reduced,  be  etherized,  and  a  second  trial  made  by  taxis.  This 
failing,  we  may  resort  to  ice  wrapped  in  flannel  over  the  tumor  for 
a  while,  which  will  condense  the  gas  and  reduce  the  parts  by  pre- 
venting a  flow  of  blood  to  the  part  and  its  return  from  the  venous 
engorgement,  then  putting  the  patient  under  chloroform  again,  and 
if  it  cannot  then  be  reduced,  resort  to  the  knife  at  once,  while 
the  patient  is  under  chloroform.  Delay  is  dangerous,  and  the  sur- 
geon whp  does  not  act  promptly  is  responsible  for  the  patient's  life. 

INCAECERATED   HERNIA. 

This  variety  is  very  much  like  the  last.  By  it  I  mean,  such  an 
impactment  of  the  contents  of  a  hernia  (it  being  irreducible),  as 
shall  obstruct  the  passage  of  the  faeces  through  the  intestinal  portion 
without  impediment  to  the  circulation  and  without  strangulation. 

The  Sympto'ins  are  an  increase  of  the  size  of  the  tumor,  pain 
and  heaviness  in  it,  without  any  pain  or  soreness  about  the  neck  of 
the  sac.  This  is  attended  with  constipation,  nausea,  and  vomiting, 
of  a  chronic  character,  while  they  are  sudden  and  acute  in  strangu- 
lated hernia. 


STRANGULATED   HERNIA.  77 

Causes. — Constipation,  accumulation  of  faeces  in  the  sac,  gas,  or 
indigestible  food.  It  is  most  common  in  old  and  debilitated  persons, 
or  persons  with  large,  prominent  bellies. 

Treatment.  —Mild  purgatives,  in  the  absence  of  vomiting,  injec- 
tions, gradual  pressure,  low  diet,  and  rest  in  the  horizontal  position. 
Stimulating  enemata,  as  turpentine,  castor  oil,  or  colocynth.  Wh^n 
some  relief  is  obtained,  the  hernia  may  be  reduced  by  taxis.  Care 
should  be  taken,  in  using  manipulation,  not  to  increase  the  accu- 
mulation, which  it  is  liable  to  do,  if  the  lower  intestines  are  not 
first  emptied. 

STRANGULATED   HERNIA. 

This  is  the  condition,  in  which  all  hernias  tend  to  result — a  con- 
striction of  the  contents  at  the  mouth  of  the  sac,  or  along  the  line 
of  its  protrusion,  hour-glass  contraction,  adhesion  and  swelling, 
becoming  so  great  that  the  contents  cannot  be  reduced  {see  Figure  5, 
page  19),  the  parts,  finally,  becoming  so  constricted  that  fecal  mat- 
ter, fluid,  or  solid,  cannot  pass  into  or  out  of  the  sac.  The  arterial 
circulation  is  cut  off,  and  the  veins,  distended,  exude  serum.  This 
condition  lasting  for  any  considerable  time  results  in  gangrene,  and 
sphacelation  of  the  contents  of  the  sac,  and  even  the  sac  itself,  as  I 
have  seen  the  testicle  completely  sphacelated  and  dead. 

If  the  strangulation  be  complete,  this  condition  will  obtain  in 
twenty-four  hours,  or  if  less,  it  may  last  to  the  fourth  or  even 
eighth  day,  and  some  may  then  relax  and  become  irreducible,  and 
thus  remain  for  years. 

Symptoms. — Pain,  heat,  swelling  and  throbbing,  at  the  ^oint  con- 
stricted. Hernial  tumor  cannot  be  reduced;  even  fluid  and  gases 
are  retained  when  the  stricture  is  very  tight.  There  is  a  soreness, 
fullness,  and  heaviness  of  the  tumor ;  patient  relaxes  the  muscles, 
and  holds  up  or  ties  up  the  tumor  directly  above  the  stricture.  Nau- 
sea, vomiting,  borborygmic  eructations,  flatulence,  colic  and  com- 
plete retention  of  the  alvine  discharges  above  the  stricture,  when  it 
is  intestinal,  but  when  it  is  omental,  ovarian,  vesical  or  visceral  alone, 
the  bowels  may  be  moved,  and  most  usually  the  patient  has  te- 
nesmus and  passes  at  first  fecal  matter,  then  mucus  with  blood,  as 
the  strangulation  continues.  The  abdomen  becomes  tender  and 
(Edematous;  all  the  symptoms  of  acute  peritonitis  are  gradually 
set  up,  which,  at  first  is  confined  to  the  seat  of  the  stricture,  but 
sooner  or  later  becomes  general.     Iliitis  comes  on,  a  reversed  peri- 


78  HERNIA. 

staltic  action  is  set  up,  and  the  patient  vomits  stercoraceous  matter, 
bile,  mucus  and  blood.  These  vomitings  are  attended  with  severe 
pain,  particularly  about  the  umbilicus,  but  become  general  as  the 
peritonitis  spreads;  a  depressed  countenance,  quick  pulse,  and 
sometimes  high  systemic  fever,  but  not  always,  as  I  have  seen 
cases  prove  fatal  with  very  little  heat  of  skin,  or  excitement  of  the 
pulse,  depending  much  on  the  acuteness  or  chronic  character  of  each 
case,  and  the  amount  of  peritoneum  involved.  Hiccough  finally  comes 
on,  pain  ceases,  heat  subsides,  and  fever  declines,  with  cold,  clammy 
sweat,  sunken  eyes,  and  death. 

Causes — are  indirect  or  direct.  All  the  causes  of  hernia  may  be 
considered  as  indirect,  as  every  condition  producing  a  hernia  con- 
tinued becomes  in  the  end  a  cause  of  strangulation,  and,  as  we  have 
remarked,  all  hernias  indirectly  tend  to  strangulation. 

Direct  Causes — There  are  natural  or  unnatural  contractions  at 
the  point  of  stricture,  usually,  as  we  have  seen,  at  the  neck  of  the 
sac,  or  in  cases  of  inguinal  hernia,  at  the  internal  or  external  ring. 
At  every  point  where  adhesion  of  sac  and  contents  have  taken 
place,  this  adhesion,  increasing,  prevents  the  proper  nourishment  of 
the  part,  and  heat  and  swelling  increase  this  until  complete  stran- 
gulation takes  place.  Often  the  accumulation  of  cherry-stones,  water- 
melon seeds,  worms,  scybillse,  causes  impaction,  as  we  have  seen,  and 
this  produces  distention  of  the  sac,  and  consequent  pressure  at 
the  neck,  causing  effusion  of  lymph  and  the  agglutination  of  the  two 
serous  coats,  as  they  lie  over  each  other.  The  sac  gradually 
becomes  distended,  hot,  livid,  (if  the  integuments  are  tightly  dis- 
tended) gaseous,  and  of  a  bladderly  feel — feels  like  a  bladder 
blown  up,  or  distended  with  water  and  soft  foreign  substances. 

These  symptoms  are  generally  sufficient  to  diagnose  every  case 
of  hernia  from  any  other  tumor.  And  as  certain  hernias  are  more 
difficult  than  others,  we  will  speak  of  these  special  symptoms  when 
we  come  to  treat  of  special  hernias.  Plate  iii,  G,  page  17,  shows 
the  pathological  condition  of  the  intestines  in  strangulated  hernia. 

Treatment. — This  consists  in  1.  Taxis.  2.  Position  and  rupture 
(Barron  Suiten's  method).  3.  Herniotomy  or  kelotomy  (a  direct 
resort  to  the  knife).  These  means  are  assisted  by  anodynes,  as 
opium,  chloroform,  ether,  warm  bath,  venesection,  injection,  with  or 
without  sedatives.  Tobacco  injections  were  much  used  once,  but  have 
no  doubt  killed  more  than  they  benefited.  I  myself,  have  seen  one 
well-marked  case  (see  case  under  ventral  hernia  from  an  old  burn). 


STRANGULATED   HERNIA.  79 

They  are  now  almost  entirely  abandoned,  or  given  with  great  care. 
But  injections  of  warm  water,  with  0.  Burn's  hydraulic  syringe, 
or  any  of  the  improved  rubber  syringes,  will  answer  very  well  and 
very  much  assist  the  taxis  and  position  processes. 

Taxis — Adjustion — from  tasso,  to  adjust,  arrange.  The  patient 
is  placed  in  a  position  to  relax,  as  much  as  possible,  the  muscles 
around  the  tumor,  and  draw  the  body  of  the  intestines  and  omen- 
tum from  the  mouth  of  the  sac.  The  tumor,  if  not  large,  is  stead- 
ied with  one  hand,  while  the  other  gently  seizes  the  protrusion  and 
presses  gradually  and  gently,  the  contents  toward  the  point  of 
rupture,  and  directly  in  the  line  of  its  protrusion.  If  the  tumor 
is  very  large,  both  hands  must  be  used,  with  the  fingers  press- 
ing upward  from  the  fundus  of  the  tumor;  this  may  be  continued 
from  fifteen  to  thirty  minutes.  Then,  not  succeeding,  the  patient 
is  put  under  ether  or  chloroform;  and  another  attempt  made  in  the 
same  way,  no  violence  being  used,  but,  on  the  contrary,  the  most 
careful  and  gentle  pressure  is  made  for  fifteen  to  thirty  minutes. 
Then  failing,  the  patient  is  put  in  a  warm  bath ;  enemata  used ;  or 
ice  must  be  applied,  wrapped  in  flannel,  over  the  tumor,  to  prevent 
gangrene;  or  chloroform  given  a  second  time;  and  this  time  fail- 
ing, the  surgeon  ought  to  resort  immediately  to  an  operation,  with- 
out letting  his  patient  come  out  from  under  the  influence  of  chloro- 
form, as  further  attempts  and  delays  are  dangerous.  The  intestine 
will  sphacelate  and  its  contents  be  poured  out,  or  the  mortification 
will  spread  to  contiguous  parts,  and  produce  general  gangrene, 
resulting  in  death. 

Failing  in  the  taxis,  Baron  Suiten  resorted  to  rupturing  the 
stricture  by  forcibly  pushing  the  fingers  under  the  constricted  part 
and  then  returning  the  sac.  This,  at  once,  will  be  seen  to  be  a 
dangerous  proceeding,  as  the  sac  may  be  returned  without  relief  of 
the  stricture,  and  the  symptoms  will  only  be  increased  and  the 
cure  more  complicated,  by  taking  away  the  relief  that  may  be 
afforded  in  an  artificial  anus,  if  the  intestines  or  contents  be  found 
too  much  distended  to  admit  of  this  being  returned  to  the  perito- 
neal cavity.  The  same  objection  holds  good,  as  we  have  seen,  in 
the  subcutaneous  incision  of  the  stricture.  No  one  would  resort  to 
this  process,  if  they  were  not  too  ignorant  or  timid  to  resort  to 
the  knife  when  I  think  it  ought  to  be  used,  as  it  does  give  the 
patient  a  better  chance  than  to  leave  him  alone. 

Strangulated  hernias  have  been  reduced  where  they  are  chronic,  in 


80 


HERNIA. 


this  character,  by  suspension  of  the  body  from  the  lower  extremi- 
ties, allowing  the  intestines  to  pull  themselves  out,  and  assisting 
the  regurgitation  of  any  fecal  matter  or  fluids  that  may  have  accu- 
mulated in  the  sac.  This  may  also  be  aided  by  the  taxis  at  the 
tumor,  and  by  kneading  and  pulling  the  abdomen  from  the  strict- 
ure. When  the  taxis,  judiciously  used,  and  for  a  sufficient  length 
of  time,  fails,  these  methods  will  also  fail,  and  the 
surgeon  ought  to  resort  to  herniotomy. 


Fig.  28. 


HEENIOTOMY. 

This  is  usually  performed  in  the  following  man- 
ner :  Patient  anaesthetized ;  the  surgeon  takes  hold 
of  the  skin  above  the  tumor,  and  pulls  it  up  as  high 
as  he  can,  and  runs  a  bistoury  straight  through  the 
integuments  down  to  the  special  coverings  of  the 
sac,  and  cuts  from  within  out,  with  the  knife  held 
in  fourth  position,  or  he  may  take  hold  of  the  knife 
in  first  position,  and  steadying  the  tumor  with  fin- 
ger and  thumb  of  the  left  hand,  and  making  the 
tumor  tense,  cut  directly  down  through  the  skin  and 
superficial  fascia,  making  a  straight  or  compound 

cut,  as  seen  in  the  figures,     |     >  >  ;  Y.  & 

V.  I  always  make  the  incision  in  a  straight  line, 
to  enable  me  the  better  to  close  the  wound  with  a 
silver  wire,  and  thereby  to  produce  a  complete  and 
radical  cure  of  the  hernia  after  all  operations  for 
strangulation.  Sometimes  it  is  more  convenient 
to  make  the  incision  transverse  across  the  tumor, 
just  below  the  stricture,  as  it  enables  us  the  more 
readily  to  cut  the  stricture  at  the  most  favorable 
point,  as  in  cases  of  ventral  or  lumbral  hernia,  but 
the  most  usual  incision  is  directly  longitudinal  with 
the  tumor  and  over  its  line  of  protrusion.  This  in- 
cision being  made,  we  take  a  grooved  director,  and 
probe-pointed  bistoury  (Figure  28),  and  enlarge  it, 
upward  and  downward,  as  far  as  is  deemed  neces- 
sary. I  prefer  a  full  incision,  so  that  the  contents 
can  be  well  exposed  and  carefully  examined  before 
returning  them  to  the  abdomen.     I  always  examine  the  contents 


Probe-pointed 
Bistoury. 


HEENIOTOMY. 


81 


Vs 


before  cutting  the  stricture,  as  well  as  after,  as  thereby  we  get  a 
better  knowledge  of  its  condition. 

Having  fully  exposed  the  hernial  contents  by  continuing  our  in- 
cision, by  pinching  up  a  small  piece  of  the  folds  of  the  coverings  at 
their  most  prominent  points,  and  nicking  a  hole  in  them  with  the 
point  of  the  bistoury,  held  flatwise,  so  as  not  to  cut  the  intestine  or 
omentum  if  we  should  have  reached  the  sac,  we  then  slip  under 
this  fold  the  grooved  director,  and  cut  up  and  down  to  the  size  of 
the  first  incision,  if  necessary,  but  generally  a  small  opening  is  the 
best,  first  feeling  over  the  grooved  director  to  see  if  there  be  any 
artery  crossing  its  line,  and  if  so,  tie  it  before  cutting,  to  prevent 
any  hemorrhage  that  might  obscure  the  incision,  and  prevent  as 
careful  an  examination  fig.  29. 

as  is  necessary.  When 
we  reach  the  sac,  it  is 
generally  known  by  its 
whitish,  glistening 
character  and  its  irri- 
tated red  lines,  and  if 
the  hernia  has  1 0  n  g 
been  strangulated,  or 
has  been  rudely  han- 
dled in  attempting  the 
taxis,  it  will  be  livid  in 
parts,  indicating  a  ten- 
dency to  gangrene. 

The  sac  is  opened 
by  pinching  up  a  little  fold  of  it,  and  nicking  it  as  before,  to  enable 
us  to  put  in  our  director  (when  there  will  flow  out  serum,  sometimes 
as  clear  as  water,  dark-brown,  and  even  mixed  with  blood  and  fecal 
matter),  and  this  should  be  carefully  performed  if  the  case  has  been 
let  stand  till  mortification  has  taken  place ;  if  the  sac  be  recent,  we 
can  generally  see  the  director  through  its  covering,  and  being  fully 
assured  that  no  fold  of  omentum,  or  particularly  intestine,  is  be- 
tween it  and  the  director,  we  slit  it  up,  exposing  the  contents, 
which,  as  we  have  said,  should  then  be  carefully  examined,  and  if 
the  part  is  black  and  cold,  or  pieces  of  fish  or  chicken  bones,  or 
seeds,  are  found  with  fecal  matter,  we  may  know  the  intestine  has 
been  badly  ruptured,  and  that  it  is  not  fit  to  be  returned ;  we  then 
excise  the  dead  part,  and  make  an  artificial  anus  by  pulling  down 
and  stitching  the  healthy  portion  of  the  intestine  over  the  skin. 


Cutting  the  Stricture  in  Herniotomy, 


82  HERNIA. 

This  being  done,  we  cut  the  stricture,  by  putting  our  finger  (see 
Figure  29)  under  the  line  of  stricture,  and  with  the  probe- 
pointed  bistoury,  made  dull  by  running  it  over  the  back  of  a  scalpel, 
and  putting  it  in  flatwise,  we  turn  it  directly  up,  and  cut  the 
stricture  upward.  This  being  done,  the  wound  is  dressed  with 
cotton  saturated  with  permanganate  of  potash,  and  patient  given  a 
dose  of  morphine.  If,  on  the  other  hand,  we  find  the  tumor  livid, 
but  will  whiten  upon  pressure,  and  when  taken  again,  return  red, 
and  it  is  warm,  with  no  ruptured  holes  (they  may  be  as  small 
as  a  pin-hole,  and  from  one  to  many),  or  dark  livid,  or  yellow,  or 
grayish  spots,  the  stricture  may  be  cut  and  the  intestine  returned. 
But  should  we  find  any  of  these  symptoms,  the  stricture  should 
be  cut,  but  left  in  place,  and  dressed  as  before,  with  permanganate 
of  potash,  and  covered  with  oil  silk  or  elastic  cloth^  and  a  gentle 
compress  used,  to  prevent  its  enlarging.  Patient  kept  perfectly 
quiet  in  bed.  If  there  is  vitality  enough  left  in  the  part  protruded, 
in  a  few  days  it  will  be  restored  to  its  natural  color,  and  it  will 
then  return  by  pressure,  and  make  a  good  result.  This  is  the  pro- 
cess of  Gerard,  and  he  has  made  most  favorable  reports  of  success. 

The  Method  of  Petit. — He  and  his  followers  divide  the  stricture 
without  opening  the  sac,  and  speak  in  the  most  favorable  terms  of 
it,  but  it  is  now  limited  to  the  following  conditions :  Large  hernia — 
recent,  or  chronic  in  their  strangulation,  where  no  contusions,  lacera- 
tions, or  ruptures  are  suspected,  and  where  the  operation  is  performed 
before  vomitings  have  commenced.  This  limits  it  to  a  very  few 
cases  as  seen  by  the  surgeon,  especially  in  hospital  practice.  It  is 
attended  with  the  following  dangers  :  A  sac  may  be  returned  with 
its  contents  still  strangulated,  especially  where  the  stricture  is  of 
the  second  variety,  that  is,  where  the  stricture  is  at  the  neck  or  in 
the  body  of  the  sac,  as  is  usually  the  case  in  femoral  and  crural 
hernia.  Where  the  stricture  is  outside  of  the  sac,  the  hernia  hav- 
ing been  reduced,  the  sac  expands,  and  patient  does  well,  as  he  is 
not  so  liable  to  peritonitis  or  hemorrhage  after  reduction. 

From  the  great  success  attending  this  method,  we  think  it  ought 
to  be  resorted  to  in  all  favorable  cases,  though  the  statistics  are 
faulty  in  this  respect,  that  the  cases  have  to  be  selected,  and 
only  the  most  favorable  ones  thus  treated;  and  thus  it  becomes  a 
question,  if  there  be  any  real  advantage  in  it  at  last,  and  if  the 
mortality  would  not  be  equally  small,  if  the  sac  had  been  opened. 
It  is  certainly  attended  with  great  danger  of  the  hernia  being 
returned  in  mass,  and  of  one  portion  of  the  intestine  being  ad- 


HERNIOTOMY. 


83 


hered  to  another,  or  to  the  omentum,  or  wrapped  up  in  it,  several 
examples  of  which  are  known  to  have  occurred,  resulting  in  stran- 
gulation, and  requiring  the  compress  still  to  be  opened,  and  the 
sac  with  its  contents  again  brought  out,  and  the  stricture  cut. 
This  may  be  done  by  getting  the  patient  to  cough,  sit  or  stand  up, 
and  still  failing,  it  must  be  sought  for  through  the  opening  and 
brought  out,  even  if  the  incision  has  to  be  enlarged. 

Gays  Method. — A  modification  of  Petit's.  He  makes  a  small 
opening  near  the  neck  of  the  sac,  inserts  the  finger  and  searches 
for  the  seat  of  the  stricture;  having  found  it,  he  inserts  along  the 
finger  a  concealed  bistoury,  between  the  neck  of  the  sac  and  the 
stricture,  which  is  then  protruded  and  the  stricture  cut.  It  is  pecu- 
liarl}^  adapted  to  femoral  hernia.  The  prognosis,  after  operations 
for  strangulated  hernia  may  be  seen  from  the  following  statistics : — 


Authors, 

Number  of  operations. 

Sac  opened. 

Sac  not 
opened. 

Cures. 

Deaths. 

Date. 

No. 

Variety  of 
hernia. 

1 

1 

I.  L.  Petit, 

1718 

1 

Femoral 

Eavater, 

1750 

3 

.  ■  ■  • 

3 

3 

E.  W.  Wimer, 

1868 

48 

Nearly  all 
inguinal 

Not  stated 

Not  stated 

26 

8 

Erichsen, 

,  , 

47.7  per  ct. 

23.5  per  ct. 

.  , 

Luke, 

84 

Not  stated 

25 

8 

1    " 

" 

u 

59 

Not  stated 

7 

Mr.  Ward, 

155 

.... 

153 

36 

Sir  A.  Cooper, 

77 

Not  stated 

77 

36 

Dr.  Turner, 

545 

(( 

545 

•    •    >    • 

260 

Luke, 

31 

Femoral 

24 

7 

Not  stated 

N.S. 

" 

20 

Not  stated 

13 

7 

(( 

N.  S. 

Guy, 

118 

Femoral 

100 

56 

44 

11 

" 

16 

6 

The  following  table  shows  the  number  of  days : 


Authors. 


Gross. 


Luke. 


Burkett. 


Date.      Variety  of  Hernia.      Days 


1872 


Days. 

Cases. 

1 

49 

3 

41 

3 

9 

4 

5 

5 

4 

6 

7 

10 

3 

Recoveries. 


43 
30 
3 
2 
0 
3 
0 


Deaths. 


6 
11 
6 
3 
4 
4 
3 


69  cases.    Variety  not  stated.    "Within  2  days  12  died,  1  in  5.7.    00 
Variety  not  stated.    After  2  days  15  died,  1  in  2.5. 

TABLE  OP  THE  PERIOD  OF  SURVIVAL. 
In  20  cases,  1  survived  17  days.  5  survived  24  hours,  and  less  than  4B 
hours.  4  survived  48  hours,  and  less  than  72  hours.  1  survived  72  hours, 
and  less  than  96  hours.  1  survived  96  hours,  and  less  than  120  hours.  8 
survived  144  hours,  and  less  than  168.  1  survived  168  hours,  and  less  than 
192  hours.    3  survived  over  192  hours. 


84 


HERNIA. 


^ 

-I 

T-H 

C<I 

^ 

CD 

>    •-© 

g  o-^-S    . 

• 

0) 

■ot'3  ^ 

t>> 

&1 

to 

'to  pec 

sit 

^ 

c^ 

IM 

IM 

c 

i 

.'S'^' 

1 

o 

It 

fl' 
o 

53 

-1 

CO 

C<) 

o 

, 1    ^ 

, 

a 

cS   S   ro 

•«s 

eSr-; 

s 

a3  os!S 

* 

2 

sS 

=2  ^ 

a 
o 

M 

O 

00 

to 

cq 

Oi 

.2  i-O 

ft 

'M 

.ti  a. 

}-l 

.«   05   fl 

c"3 

^i 

a  rt  cs 

, 

s 

si 

oAh 

>» 

"a 
5* 

.1 

o 

o 

i« 

'-0 

cq 

<V-C 

3 

S 

S 

o    . 

45 

"S"S  2 

s 

3 

o 

5  "S 

-2<^§ 

6 

-♦J 

CSI-H 

^•3 

00 

00 

(M 

-H 

^          ^ 

fci 

-u> 

.2 

.2  ^ 

a> 

.2  ®      =s    ^ti 

1 

1 

P 

ii 

a 

-3 
<5 

'3 

o 

A* 

a 

to 

a 

.-S     ^••a'2  a 

-> 

Oi 

cq 

T-( 

^' 

a 

o 

sj 

C.2 

S  i  a 
£fS.2 

|g>§ 

A^  o  2  a   . 

o 

^ 

p 

o 

a 

^-2  2 

C<l 

lO 

t^' 

e 

'6 

"^l! 

J 

i 

fa^ 

"3 

Is 

0) 

a 

> 

a> 

^g^s 

tfH 

1) 

^ 

^^ 

■a 

HJ 

£i 

" 

» 

c-q 

c^:i 

i~~ 

t^ 

on 

cc 

^ 

^ 

s 

•« 

m 

M 

• 

t>> 

<s 

»^ 

a 

S 

^ 

o 

pq 

P 

HERNIAS   OF   PAETICULAE   EEGIONS. 


85 


HEENIAS   OF   PAETICULAE   EEGIONS. 

In  our  diagram,  Plate  1,  fig.so. 

Fig.  1,  page  13,  and  the  dy- 
cotinous  table  of  hernia,  we 
have  sufficiently  given  and 
illustrated  what  we  mean  by 
special  hernias,  or  hernias 
of  particular  regions.  But 
to  classify  them  for  more  con- 
venient use,  we  have  modi- 
fied the  following  table  from 
that  usually  given,  so  as  to 
introduce  the  most  common 
first,  and  to  ascend  instead 
of  descending  in  our  descrip- 
tion. And  this  table  further 
illustrates  what  we  have  be- 
fore stated,  that  the  down- 
ward pressure  of  the  intes- 
tines and  relaxation  of  the 
mesentery  and  mesocolons 
are  great  predisposing  causes 
of  hernia.  Making  the  in- 
guinal, scrotal  and  femoral 
the  most  common ;  the  um- 
bilical, ventral  and  lumbral, 
next  most  usually  met  with, 
and  lastly,  the  epigastric, 
diaphragmatic  and  hypo- 
chondric,  the  least  common.  The  three  belts  in  Fig.  30,  mark  the 
lines  of  these  three  grand  divisions. 


AA.  Umbilical  Line.  BB.  Hypogastric  Line. 
DD.  Hypochondric  Region.  CC.  Hypo- 
chondric  Spaces,  dd.  Diaphragm.  E.  Epi- 
gastric Space,  ff.  Lumbral  Space.  G.  Left 
Lobeof  Liver.  J.  Ventral  Space.  KL.  Spine 
of  Ilium.    M.  Vesical  Space.    MMM.  Colon. 


(I.)  Inguinal  j  (a.)  Oblique  inguinal, 
oblique.      1  (6.)  Direct.  " 

r  Hernias  of  sudden  descent  are 
(1.)  In  the    J  (a.)  Spermatic  process. 


■\  (1.)  The  scro- 
'  tal,  ia  male, 
r  (2.)  Labial,  in 


female. 


(1.)  In  inguinal  re-, 
gion  are  found     ] 


male. 


(2.)  In  the 
female. 

^(11.)  Direct. 


t(6.)  Funicular 
(c.)  Inguino-crural. 
r  Hernias  of  gradual  develop- 
j  ment,  are 

1  (a.)  Inguino-crural. 
\{b.)  Encysted — Infantile. 
Utero-ovarian  process — canal  of 

Xuck. 
(&.)  Inguinal-labial. 


86 


HERNIA. 


II. 

Femoral  or  Crural. 
III. 

Pelvis.     1.  Anterior- 

2.  Inferior. 


-Obturator. 


1.  Perineal. 

2.  Pudendic. 

3.  Vaginal. 


3.  Posterior — Isehiatic. 
I. — Hernia  in  Mesogastric  Region. 

1.  Ventral  (may  occur  in  other  regions,  see  Plate  l). 

2.  Umbilical. 

3.  Lumbral. 

II. — Hernia  in  Epigastric  Region. 

1.  Diaphragmatic,  Right  and  Left. 

3.  Epigastric. 

3.  Hypochondric,  Right  and  Left. 
III. — Internal  Hernias. 

1.  Intestinal. 

2.  Intusceptive. 

3.  Diverticular  (see  plate  3  E). 

We  will  now  describe  each  of  these  in  the  order  in  which  they 
come  in  this  table,  under  the  following  heads  :— 

1.  Sym/ptoms.  2.  Causes.  3.  Diagnosis.  4.  Prognosis.  5. 
Coverings.  6.  Character:  (a.)  Reducible;  (b.)  Irreducible; 
(c.)  Inflamed;  [d.)  Impacted;  (e.)  Strangulated.  7.  Treatment: 
(a.)  Palliative ;  (6.)  Curative,  (a.  Palliative,  by  Reduction,  Truss. 
Bandages,  etc.  (6.)  Curative,  by  reduction,  truss,  and  various 
operative  processes  and  methods.  8.  Batio  of  Mortality.  9. 
Pathological  Conditions  after  Death.  10.  Number  of  Days  Sick  ; 
Number  of  Days  under  Treatment.     11.   General  Remarks. 

HERNIAS   OF    THE   HYPOGASTRIC   REGION. 

Inguinal  is  by  far  the  most 
common  form  in  which  we 
find  hernia,  about  three  to 
one  of  all  other  varieties. 
Its  symptoms  are  generally 
very  plain,  and  as  it  is  the 
most  common  form,  when  we 
have  an  obscure  case,  we 
should  examine  this  region 
most  carefully.  It  shows  it- 
self by  a  tumor  at  the  in- 
ternal ring,  sometimes  not 
larger  than  a  knuckle,  and 
then  as  large  as  an  egg  (see 
Fig.  31).  It  continues  to 
increase  and  distend  until  it  appears  at  the  external  ring  (a),  left 


Fi&.  31. 


Inguinal  Hernia;  on  the  Right  Side,  Oblique, 
on  the  Left  Direct,  (a.)  The  Hernial  Sac. 
(b.)  The  Epigastric  Arterj^. 


HERNIAS   OF   THE    HYPOGASTRIC   REGION.  87 

side,  and  becomes  a  complete  oblique  inguinal  hernia.  In  its  course 
it  directly  follows  down  the  spermatic  cord,  and  usually  lies  above 
it,  but  is  found  to  the  right  or  left,  and  where  the  testicle  is  retained 
in  the  abdomen  it  may  come  out  at  the  internal  ring,  and  place  the 
testicle  above  and  the  cord  in  front.  Instead  of  its  taking  its  course 
obliquely  from  the  internal  ring,  it  may  come  directly  through,  form- 
ing a  direct  inguinal  hernia,  at  the  upper  or  internal  ring,  or  it  may, 
as  seen  at  (a),  left  side,  burst  through  at  the  lower  ring,  pushing  the 
cord  to  the  right  or  left,  and  coming  out  above  the  ilio-pubic  liga- 
ment, which  distinguishes  this  variety  from  femoral  and  ventral. 
The  sac  lies  immediately  over  Poupart's  ligament  (ilio-pubie,  as  we 
prefer  to  call  it).  When  it  comes  out  at  the  upper  ring,  it  is  about 
one  inch  and  a  half  above  the  ilio-pubic  ligament,  and  half  an  inch 
to  the  inner  side  of  it.  So  any  tumor  in  this  line  that  is  reducible, 
returns  with  a  gurgling  sound,  and  seems  to  slip  suddenly  from 
under  the  fingers,  having  a  hole  that  the  finger  may  be  put  in,  is  a 
reducible  inguinal  hernia ;  but  it  may  become  strangulated  between 
the  rings,  or  it  may  not  appear  at  the  external  ring,  but  bulges  out, 
in  coughing,  laughing,  riding,  or  lifting,  and  will  return  of  itself. 
This  is  an  incomplete  inguinal  hernia,  and  if  the  parts  are  not  sup- 
ported, will  continue  until  it  becomes  of  considerable  size,  and 
pulling  the  septum  down,  it  will  fall  immediately  above  the  ilio- 
pubic ligament,  making  an  old  oblique  inguinal  hernia ;  direct,  and 
continuing  its  course  down  along  the  spermatic  cord,  or  the  round 
hgament  in  the  female,  it  finally  appears  in  the  scrotum  of  the 
male,  forming  scrotal  hernia,  or  the  labia,  forming  labial  hernia  in 
the  female.  The  scrotum  being  of  an  expansive  tissue,  it  enlarges 
and  descends  until  it  nearly  reaches  the  knees  in  some  cases,  and 
is  quite  common,  of  the  size  in  the  figure,  in  children  of  only  a  few 
months  or  years  old.  In  the  celebrated  Gibbon,  nearly  all  the  con- 
tents of  the  abdomen  came  down,  and  it  reached  nearly  to  his  knees. 
Such  cases  are  not,  unusual ;  most  authors  have  seen  such.  The  sac 
of  inguinal  hernia  may  form  gradually,  or  it  may  be  produced  sud- 
denly, as  I  once  saw  in  a  soldier,  from  jumping  what  is  called  a  half 
hammer.  He  fell  over,  as  it  were,  on  his  knees,  burst  up  the  ring,  and 
the  intestine  came  out  immediately,  the  size  of  a  turkey's  egg,  pro- 
ducing great  pain,  and  a  disposition  to  bend  over,  with  sick  stomach 
coming  on  almost  instantly.  I  immediately  alighted  from  my 
horse,  as  I  was  riding  through  camp,  and  reduced  it,  put  on  a  good 
truss,  and  heard  no  more  from  the  case ;  the  pain  ceased  imme- 


88  HERNIA. 

diately  on  its  reduction,  as  well  as  the  vomiting.  When  the  sac 
thus  forms  suddenly,  it  is  thin  and  transparent,  and  the  coverings 
above  the  hernia  may  be  well  made  out ;  but  if  the  sac  is  old  and 
slow  in  formation,  it  will  become  thick  and  filled  with  deposits  of 
floating  lymph,  which  will  be  found  in  it  on  opening  the  sac.  The 
coverings  will  be  so  pressed  together  that  it  will  be  impossible  to 
distinguish  one  from  the  other,  after  passing  the  skin  and  superfi- 
cial fascia  (see  Fig.  32).  If 
the  hernia  be  an  enterocele, 
it  will  be  very  elastic,  and 
have  a  light  gaseous  feel, 
and  when  reduced,  will  be 
attended  with  a  crackling 
sound.  If,  on  the  other 
hand,  the  contents  of  the  sac 
be  omentum  or  an  epiplo- 
cele,  it  will  have  a  more  solid 
doughy  feel,  and  when  re- 

ScrotalHernia;^mg  the  Usual  Relation  of  duced,    will    return    with    a 
the  Sac  to  the  Vaginal  Tunic.  a  £•  p  ^^  fl^p^"  gliQwing   it   is 

a  more  solid  mass.  When  it  is  an  entero-epiplocele,  it  will  com- 
bine these  two  symptoms,  and  the  two  portions  may  be  felt  re- 
turning at  different  times,  first  the  intestine,  and  then  the  omentum; 
or  if  they  be  adherent,  they  may  return  at  once,  with  a  gurgling 
and  jumping  sensation.  The  same  symptoms  will  be  more  or  less 
acute  if  the  spleen  or  kidney  is  included,  but  these  give  more 
solid  sensation  to  the  fingers  than  even  the  omentum.  Where 
this  hernia  occurs  before  birth,  it  is  called  congenital,  and  is  of 
that  variety  we  have  named  spermatic  in  males,  and  ligamentic 
in  females.  Where  the  hernia  forms  in  the  upper  portion  of  the 
tunica  propria  cordse  spermaticse  (called  vaginal  process),  following 
down  the  testicle,  and  in  females,  where  it  forms  in  the  upper  por- 
tion of  the  round  ligament,  or  in  the  tunica  propria  cordae  rotundse, 
it  is  usually  called  the  vaginal  process  of  the  round  ligament,  but  we 
never  use  these  terms — as  vaginal  should  alone  be  applied  to  the 
vagina — when  speaking  of  hernias  of  the  hypogastric  region. 

FUNICULATED   HERNIA,  USUALLY   CALLED   IMPACTED    OR   ENCYSTED 
HERNIA   IN   THE   TUNICA  PROPRIA  FUNICULI  TESTIS. 

This  variety  forms  in  early  childhood,  or  may  be  congenital. 
The  internal  ring  is  closed,  but  the  spermatic  cord  is  surrounded 


ENCYSTED   HERNIA. 


89 


below  with  an  enclosed  serous  coat,  or  it  has  a  sac  into  which  the 
intestines  or  omentum  is  pressed,  leaving  the  internal  ring  above, 
and  sometimes  the  testicle ;  then  following  down  the  cord  to  the 
scrotum  may  become  scrotal,  or  to  the  labia,  forming  inguinal 
labial  hernia  of  the  infantile  or  encysted  type. 

The  sac  of  congenital  spermatic  hernia,  is  what  is  called  the 
serous  coat  of  the  vaginal  process  itself,  its  mouth  being  at  the 
internal  abdominal  ring,  its  neck  and  body  occupying  the  inguinal 
canal,  which,  when  suddenly  formed,  do  not  approximate  the  inter- 
nal and  external  rings,  as  occurs  in  congenital  hernia  of  slow 
growth  or  of  long  standing. 

A  sub-variety  is  the  hour-glass  shaped  hernia,  where  the  nar- 
rowing of  the  hernial  sac  exists  between  the  testes  and  the  exter- 
nal abdominal  ring. 

Inguino-scrotal  Hernia  of  Slow  Forma- 
tion, is  represented  in  Fig.  32,  page  88 ;  this 
is  the  common  variety,  as  we  said  before ;  and 
before  it  becomes  complete,  and  while  it  lies 
under  the  tendons  of  the  external  oblique,  and 
a  fold  of  the  internal  oblique,  it  is  called  a 
bubonocele. 

The  hernia  descends  through  the  inguinal 
canal  to  the  external  ring,  and  along  the  sperm- 
atic cord  to  the  scrotum,  as  seen  in  Fig.  33, 
pushing  the  peritoneum  before  it,  and  lying  in 
front  of  the  cord,  and  increases  to  any  size. 
This  is  often  seen  in  adult  life. 

Funiculated  hernia.  Cooper's  "Hernia  of ^^^^"*"« ®«''°*^^ ^^""^^^ 
the  tunica  vaginalis,"  Hey  and  Leeds'  "  Infantile  Hernia." 


Fig.  33. 


ENCYSTED   HERNIA   (aSHHURST),  HERNIA   OP  THE   TUNICA   PROPRIA 
FUNICULI   TESTIS. 

Its  distinguishing  feature  is  that  it  is  below  the  internal  ring, 
which  is  closed,  and  the  testile  orifice  is  patulous,  into  which  the 
intestines  have  formed,  and  have  carried  with  them  the  folds  of  the 
peritoneum,  passing  into  the  tunica  propria  testis,  and  continuing  its 
course  to  the  external  ring  and  the  scrotum.  In  the  female,  to 
the  labia,  forming  labial  hernia.  This  hernia  is  said  by  Ashhurst 
to  be  of  frequent  occurrence,  and  forms  suddenly  ;  though  common 
in  infancy,  often  does  not  make  its  appearance  until  adult  life. 
7 


90 


HERNIA. 


INGUINO-SUB-INTEGUMENTAL  (See   Fig.  34). 

Fig- 34.  Inguino- Crural  Hernia.     This  hernia,  in- 

its  passage  down  into  the  scrotum  or  labium 
as  usual,  protrudes  outward  along  the  folds 
of  the  groin,  presenting  the  appearance  of  a 
crural  hernia,  hence  I  have  called  it  sub-in- 
tegumental  and  not  a  crural  hernia,  as  all 
crural  hernias  press  under  the  ilio-pubic  liga- 
ments. And  under  this  head  may  be  placed 
the  anomalies,  usually  called — 

Intra-parietal   Hernia,   where    it  passes 
under  the  parietal  wall. 

Inter-muscular,  where  it  passes  between 
inguino-sub-integumeBt-  ^^^  muscles ;  the  hemias  "  en  bissac  "  of  the 

al  Hernia.  ^^^^^^^ 

The  causes  of  the  different  varieties  of  inguinal  hernias  that 
are  peculiar  are  given  in  their  history  and  formation  above  and 
under  hernias  in  general. 

The  spermatic  and  fanatic  varieties  are  dependent,  in  a  great 
degree,  upon  their  predisposing  cause,  which  is  the  patulency  of 
portions  of  the  spermatic  cord.  The  other  causes  are  general : 
coughing,  crying,  laughing,  defecating,  are  common  in  children. 
Eiding,  lifting,  pulling,  blowing  wind  instruments,  any  and  all 
kinds  of  muscular  contractions. 

The  Diagnosis  is  generally  plain  when  we  have  all  the  symp- 
toms given  above,  but  there  are  other  reducible  and  irreducible 
tumors,  especially  found  in  the  inguinal  region,  that  may  lead  to 
grave  and  serious  results. 

We  copy  below  a  diagram  from  "  Gant's  Surgery,"  giving  them 
in  full,  which  we  advise  all  to  study  carefully.     Page  946. 


DIAGNOSIS    OF   EEDUCIBLE    TUMORS. 


91 


The  Reducible  Tumors;  Their  Entrance  or  Return  into  the  Abdomen. 


1.   Inguinal 
hernia. 


2.  Hydrocele 
of  vaginal  process 
of  peritoneum. 


3.  Hydrocele 
of  the  funicular 
portion  of  the 
vaginal  process. 


4.  Varicocele. 


CHARACTERS  IN  COMMON.     SPECIAL  CHARACTERS  IN  INCOMPLETE. 


1.  All  return  into  the  ab-  1.  Hernia  enters  most  readily  when 
domen  when  the  patient|once  commenced.  Passes  quick  and  sud- 
lies  recumbent  and  the  ab-denly.  Entrance  complete.  Thick  and 
dominal  muscles  are  re- j  opaque  neck  of  tumor.      Testis  may  or 


laxed. 


may   not  be  perceptible  until  reduced. 
No  vibration. 

2.  Hydrocele  of  vaginal  process  of  peri- 
toneum enters  slowly  and  very  suddenly. 
Entrance  complete.  Narrow  and  trans- 
lucent neck  of  tumor.  Testis  impercepti- 
ble until  the  fluid  has  entered  the  abdo- 


Their  Passage  from  Abdomen — Special 
Character. 

1.  Hernia  is  developed  from  above,  de- 
scends when  the  patient  rises  or  exerts 
the  abdominal  muscles,  and  more  quickly 
than  other.  Pressure  over  the  ring  pre- 
vents its  descent. 

2.  Hydrocele  seems  to  develop  from 
below  upward.  The  serum  sometimes 
remains  when  patient  is  recumbent, 

3.  Similar  to  No.  2. 


3.  Hydrocele  of  funicu- 
lar portion  of  vaginal  pro- 
cess enters  like  No.  2.  En- 
trance complete.  Trans- 
lucent. Flesh  of  tumor 
may  pass  into  inguinal 
canal.  Testis  perceptible 
at  fundus  of  tumor.  Vibra- 
tions. 


4.  Varicocele  enters  4.  The  tumor  increases  like  hernia  when 
very  slowly.  Entrance  the  patient  rises,  but  it  increases  also  if 
not  complete.  The  bulk  pressure  be  made  over  the  course  of  the 
of  tumor  only  diminished,  spermatic  veins  in  the  inguinal  canal,  or 
No  vibration.  jby    relaxation    of    the    blood,    however 

I  caused. 


The  tumors  to  be  diagnosed  by  the  above  rules,  and  those  that 
follow,  are — 1st.  from  hernia  undescended  into  scrotum ;  abscess  in 
the  course  of  the  inguinal  canal;  hydrocele  or  h^^matocele  of 
the  cord;  tumor  of  the  cord;  adenitis  and  undescended  testis; 
hydrocele  of  the  round  ligament  in  the  female;  serous  cysts  in 
the  tunica  ligamentis,  or  canal  of  Nuck.  2d.  From  hernia  in  the 
scrotum;  hydrocele  of  the  tunicce  alhugenia  testis;  hcematocele ; 
varicocele  and  tumors  of  the  testis  and  scrotum.  These  should 
all  be  studied  in  general  works  on  surgery,  with  all  their  relations 
and  symptoms. 


92 


HERNIA. 


S-a 


0)  a^ 


«^  '>^  aj 


<u 

T3    •    aj 

gand 

in- 

bleas 
ele  of 

Q^ 

-s.^ 

"  ,^  >."5  o 

«  r3 

.S  o 

CO 

+;,  be      --3 

Yield 
lasti 
eeding] 
ompres 
ydro 

-H 

OQ    ***       , 

®2  cug 

OC  a)  oi  g 

■a 

rt  a 

J3 

III 

s».u  o 

aj  o  o  -fi 

a 

to 

ChO 

«   _  w 

>  a  M 


ce  a 


CO 


•-'ai  • 
aj  c?W 

^    m    ^ 

"  a  " 


3^   3  -S, 
aj  oO 


w  r       ,    ^^    '^   w 

^^  Mi^'T3  o3  2  g 
o|  =  -S3°°* 

P^_rt  oj  o   aJ  rr,  -*^  ^ 
CL-SoajSoB 

t>  ^^^  ^H   00  CO   ao 


a    :::^| 


73   >-   >i  ii   O  o3 

S     O!    rt    "1     !l     S 


a  ''ji 

St  «iaj 


60V('5 

a>  o  O 

^m      aj 


a  e3 


oj  a)^t„-s  S' 


^a>3oOg^: 


03  a  a'« 
''  3 .3  S 


CD    •  a> 

a;,  >  =*H 

a>  S 

<*;  »  05 

o  <u 

CO  fe    05 

(U  a,  aj    . 

.5         C   «5 

rs  c-S  3 

3  a)   g   !jo 


2  C 


IS 

Position   va- 
riable, but  the 
testis     usually 
disseverable. 

Per  ceptible 
in  sperm  ato- 
cele;  not  in  hy- 
drocele  of   tu- 
nica   vaginalis 
propria  testis, 
usually. 

0  f  t  e  n    i  n  - 
volved  and  im- 
perc  eptible ; 
though  its  site 
may  be  discov- 
ered  by    pres- 

2 

3 

'o 

> 
a 

h- 1 

4)  m 


r'  "^ 


^^I'-'s 


■■"wi. 


^  o  n  5  -^ 


a^ 

a>  o 


a. 
O 


<D 

1. 

1 

1) 

o 

V 

> 

O 

tS 

73 

^ 

>% 

ti 

.i3 

« 

>t 

w 

ra 

a 

HI 

OS 

JS 

a) 

>.o 

S   OJ 

c3^ 

>--M 

V 

o^ 

oa 

T3 

i-H 

«« 

DIAGNOSIS   OF    REDUCIBLE   TUMORS.  93 

With  all  these  plain  rules  to  guide  us,  we  will  still  meet  with 
cases  the  true  character  of  which  nothing  but  an  operation  can 
reveal.  The  author  and  Dr.  Anger  were  compelled  to  resort  to 
the  exploring  needle,  to  distinguish  a  psoas  abscess  from  a  strangu- 
lated hernia  beneath  Poupart's  ligament.  See  report  of  case  in 
Galveston  Medical  Journal,  1866,  and  Nashville  Medical  Record, 
1858.  I  also  was  in  great  doubt  in  the  cases  of  McKim  Lea  and 
a  butcher  of  Galveston.  Mr.  Lea  had  been  using  a  badly-fitting 
truss,  and  the  hernia  had  been  reduced,  as  was  supposed,  but  there 
being  adhesions  to  the  omentum,  it  did  not  return  with  the  intes- 
tine, and  became  strangulated  and  gangrenous.  It  had  been  sup- 
posed to  be  only  a  lymphatic  gland  inflamed  from  using  a  bad 
truss,  and  the  various  attempts  to  release  it  by  taxis.  I  found  a 
small,  immovable  tumor,  very  tender  over  the  external  ring,  crack- 
ling under  pressure,  showing  emphysema.  We  cut  down  on  it, 
and  found  a  knuckle  of  omentum,  perfectly  dead,  with  grumous 
blood  all  around  it,  but  the  orifice  was  completely  closed,  and  no 
fluid  passed  into  the  abdomen.  We  cut  off  the  mass,  washed  out 
the  blood,  and  sewed  up  the  wound  with  silver  wire,  enjoining  com- 
plete rest.  He  recovered  slowly,  but  it  continued  to  discharge  pus 
and  serum  for  over  six  weeks.  He  was  radically  cured,  and  has 
had  no  return  of  his  hernia  since. 

The  butcher  had  a  sudden  rupture,  while  lifting  a  quarter  of 
beef  on  to  a  hook  in  the  market;  felt  acute  pain,  and  was  sick  at 
stomach;  very  fat.  After  two  days  he  came  to  me  with  great 
tenderness  in  the  inguinal  region,  with  a  boldly  defined  tumor  just 
above  the  ilio-pubic  ligament.  It  was  movable  and  appeared  to 
slip  back  when  pressed  on,  but  would  immediately  return.  We 
pushed  it  back  and  put  on  a  truss,  and  sent  him  home,  but  re- 
quested him,  if  not  better,  to  let  us  know  next  day,  and  we  would 
operate.  He  was  no  better,  but  worse.  We  went  and  operated  on 
him,  and  found  an  oblong  tumor  in  the  groin,  passing  up  through 
the  external  tendons,  which  was  strangulated  and  dead.  We  cut  it 
all  off  with  the  scissors,  washed  it  out  well,  and  sewed  up  the 
external  wound.  The  tumor  appeared  to  be  a  fold  of  mesentery, 
with  two  or  more  mesenteric  glands  included.  Patient  suffered 
much  from  neuralgia  of  the  crural  nerve,  but  finally  made  a  good 
recovery  and  was  radically  cured. 

I  remember  another  instance  in  which  I  had  two  boys  about 
eight  years  old  under  treatment  at  the  same  time.     One  had  an 


94  HERNIA. 

encysted  serous  tumor,  about  the  size  of  a  pullet's  egg,  under 
the  scrotum,  and  immediately  above  the  tunica  albugenia  testis, 
but  not  connected  with  it.  The  other  had  hydi^ocele  with  patulous 
cord,  and  when  the  scrotum  was  held  up  or  squeezed,  it  disappeared. 
The  encysted  tumor  was  so  soft  that,  when  pressed  on,  it  appeared 
to  pass  into  the  tunica  albugenia  testis,  but  would  return.  I  cut 
down  and  removed  the  encysted  tumor  and  made  compression  with 
a  truss  over  the  external  ring  in  the  hydrocele  case,  and  after 
closing  the  canal,  operated  on  him  and  effected  a  cure.  Both  of 
these  had  been  thought  to  be  hernias,  and  could  only  be  diagnosed 
by  the  careful  rules  given  in  the  table. 

Prognosis. — Grenerally  favorable  except  in  neglected  cases  of 
strangulated  hernia,  impacted,  inflamed,  incarcerated,  and  irreduci- 
ble, all  of  which  are  attended  with  great  danger,  either  immediate 
or  remote,  and  should  be  closely  and  promptly  attended  to. 

CHARACTERS   AND    RELATIONS. 

A  recognized  oblique  inguinal  hernia  has  for  its  internal  or 
medial  side  the  internal  tendon  of  the  transversalis  muscles;  the 
internal  layers  of  the  internal  and  external  obHque,  above  the 
inter-columnar  fascia,  and  the  peritoneum ;  above  the  peritoneum, 
infundibular  fascia;  conjoined  tendons;  superficial  fascia  and  skin. 
Outer  side,  folds  of  the  tendons  of  the  transverse  internal  and  exter- 
nal oblique  muscles. 

Its  coverings  are  seven,  the  same  as  the  spermatic  cord  receives, 
and  enumerated  from  within  to  without,  in  the  order  of  hernial 
development.  1.  Peritoneal  pouch-sac.  2.  Sub-serous  cellular 
tissue.  3.  Fascia  transversalis,  or  infundibular.  4.  Cremaster 
fascia.  5.  Intercolumnar  or  spermatic  fascia.  6.  Superficial 
fascia.  7.  Skin.  These  coverings  are  only  interesting  with  refer- 
ence to  the  development  of  oblique  inguinal  hernia,  but  they  are 
so  "  altered  in  appearance  and  united  by  pressure,  as  to  not  have 
much  importance  surgically,"  "The  relations  of  the  inguinal 
canal,  spermatic  cord  and  testicles,  to  the  visceral  protrusion,  and 
of  the  epigastric  artery  to  the  mouth  of  the  sac,  are  specially 
important." 

The  inguinal  canal  lies  about  half  an  inch  to  the  median  side 
of  the  ilio-pubic  ligament;  commencing  a  little  above  its  mid- 
dle portion,  it  extends  from  the  internal  to  the  external  ring  at  the 
crest  of  the  pubis,  obliquely,  and  parallel  with  the  ligament,  and  is 


CHARACTERS  AND   RELATIONS.  95 

about  one  and  a  half  inches  long,  in  its  natural  state.  Its  bounda- 
ries we  have  given  in  those  of  oblique  inguinal  hernia.  The  cord 
lies  behind  and  beneath  the  hernia,  in  the  common  inguino-scrotal 
hernia,  the  testis  below  and  somewhat  behind  its  fundus,  as  seen  in 
Fig.  32,  page  88.  The  elements  of  the  cord  are  sometimes  dispersed 
by  the  hernia  as  it  descends,  the  vas  deferens  being  on  one  side 
and  the  spermatic  vessels  on  the  other,  and  entirely  in  front  of  the 
hernia,  and  the  testis  below  is  also  in  front.  The  epigastric  artery, 
arises  about  half  an  inch  from  the  ilio-pubic  ligament,  and 
bends  toward  the  median  line,  and  ascending,  passes  into  the  fascia 
transversalis,  immediately  behind  and  internal  to  the  mouth  of 
the  sac,  running  obliquely  upward  and  toward  the  median  line, 
between  the  external  and  internal  rings.  Its  course  varies  as  to 
the  position  of  the  rings,  as  they  approximate  in  old  hernias  (they 
pushing  it  around  and  outside  of  the  external  ring)  and  by  its 
abnormal  course,  which  occurs  very  rarely,  but  may  come  from 
the  internal  trunk  of  the  iliac,  from  the  back  of  the  ligament,  as 
high  as  two  inches  and  a  half  above  it,  from  the  obturator  instead 
of  the  iliac,  or  from  below  the  ligament,  arising  from  the  femoral 
artery.  The  first  does  not  interfere,  in  inguinal  hernia,  at  the 
internal  abdominal  ring,  but  the  two  last  may  have  special  rela- 
tion to  the  crural  ring,  and  therefore  to  femoral  hernia.  The  seat 
of  the  stricture  is  most  usually  at  the  mouth  of  the  sac  and  the 
internal  ring,  and  next  at  the  border  of  the  internal  oblique  muscles 
in  the  canal;  lastly  at  the  external  abdominal  ring. 

2.  Direct  inguinal  hernia,  common  to  both  male  and  female. 

Symptoms  are,  in  general,  those  of  oblique ;  and  the  causes  are 
the  same,  except  the  predisposing,  as  congenital  malformations; 
consequently,  its  course  is  nearly  direct,  and  the  same  as  oblique, 
which  see. 

Its  diagnosis  is  more  easily  made  out.  1.  It  is  more  easily  re- 
duced, and  goes  straight  through  to  the  abdominal  cavity.  2.  It 
is  harder  to  retain  by  trusses  and  bandages.  Progresses  more 
rapidly.  3.  It  comes  out  in  a  small,  triangular  space,  bounded, 
externally,  by  the  epigastric  artery,  the  margin  of  the  rectus  mus- 
cle on  the  outer  side,  and  the  ilio-pubic  ligament;  its  inner  portion, 
below.  This  triangle  is  called  the  triangle  of  Husselmarch,  and  is 
immediately  behind  the  external  ring,  with  the  conjoined  tendon 
and  the  fascia  transversalis  intervening.  The  coverings  are  seven, 
as  in  oblique  inguinal,  and  are  the  same  in  kind,  with  the  excep- 


96  HEENIA. 

tion  of  tlie  conjoined  tendon,  whicli  takes  the  place  of  the  cremas- 
ter  fascia.  Then  numbering  them  in  the  order  of  development, 
they  are :  1.  Peritoneal  pouch  or  sac ;  2.  sub-serous  cellular  tissue ; 
3.  fascia  transversalis ;  4.  conjoined  tendon  (sometimes  ruptured); 
5.  intercolumnar  fascia;  6.  superficial  fascia;  and  7.  skin.  The 
spermatic  cord  lies  on  the  outer  side  of  the  sac,  the  testicle  below 
the  fundus,  and  both  are  distinctly  separate.  The  epigastric  artery 
also  courses  up  external  to  the  mouth  of  the  sac,  curving  over  it 
inward,  so  as  to  sometimes  enclose  the  upper  as  well  as  the  outer 
margin. 

Seat  of  stricture.  1.  at  mouth  of  sac;  2.  (when  tendons  are 
ruptured)  at  the  conjoined  tendons ;  3.  at  the  external  abdominal 
ring.     See  Figs.  423  and  430  (Ashhurst). 

In  the  female,  obHque  and  direct  hernia  have  the  same  anatomi- 
cal relation,  except  the  spermatic  cord  is  substituted  for  the  round 
ligament.  The  oblique  occurs,  as  in  males,  very  early,  as  we  have 
seen,  in  life.  Except  umbilical,  oblique  inguinal  is  the  only  kind 
developed  before  five  years  of  age  (Gant,  page  941),  and  until  the 
age  of  puberty,  is  more  common  than  any  other  variety.  This 
form  is  now  much  more  rarely  met  with  than  formerly,  as  generally 
supposed.  Thus,  in  Mr.  Ringdon's  observations,  made  on  all  varieties 
of  hernia,  in  1582  cases  761  had  inguinal  hernia,  and  812  femoral. 
Being  thirty  less  than  femoral,  and  femoral  only  being  thirty,  more 
than  one  half  of  those  of  inguinal. 

The  tumor  of  direct  hernia  dififers  in  shape  and  size,  as  well  as 
situation,  from  oblique;  comes  out  near  the  root  of  the  penis; 
globular  in  shape,  not  pyriform,  as  oblique,  has  a  wider  neck,  and  is 
not,  generally,  so  large.  Both  may  be  double,  an  incomplete  one 
on  one  side,  and  a  complete  one  on  the  other. 

TreatTnent  of  inguinal  hernias,  like  hernias  in  general,  consists 
in  palliative  and  curative.  Reducible  oblique  inguinal  hernia  is 
better  adapted  to  the  palliative,  and  some  of  the  processes  of  radi- 
cal cure,  than  any  other.  It  is  more  difficult  to  reduce  when  it  is 
incarcerated  or  strangulated,  than  any  other,  except,  perhaps, 
femoral.  Before  resorting  to  any  palliative  treatment,  the  hernia 
should  be  perfectly  reduced,  whether  it  can  be  done  by  taxis,  by 
Suiten's  method,  by  position,  or  by  an  operation  with  the  knife. 

The  Taxis. — The  bladder  and  rectum  being  emptied,  the  patient 
is  put  on  his  back,  hips  raised,  body  lowered,  head  and  neck  bent 
on  body,  legs  flexed  on  the  thighs,  and  held  close  together  with 


CHARACTEES   AND   RELATIONS.  97 

toes  everted  to  table.  In  this  position  the  surgeon  takes  hold  of 
the  tumor  at  its  neck  with  the  left  hand,  and  gently  pushes  and 
pulls  downward,  while  the  right,  with  the  palm  of  the  hand  hold- 
ing the  tumor,  pushes  the  fundus  upward  with  a  kneading  motion, 
and  the  hernia  begins  to  disappear  with  a  gurgling  sound,  and 
finally,  slips  from  under  the  hand,  leaving  a  hole  that  the  finger 
may  be  put  into.  If  the  contents  are  omentum  it  will  return  with 
a  jump,  or  jerk,  or  "  flip  flap  "  sound.  If  it  be  entero-epiplocele,  we 
will  have  the  two  sensations  combined ;  usually,  the  bowel  is  re- 
turned first.  The  pressure  should  always  be  made  in  the  line  of 
descent ;  and  in  oblique  inguinal  hernia  it  should  be  made  upward 
and  outward,  along  the  line  of  the  ilio-pubic  ligament.  In  direct, 
it  should  be  pushed  downward  and  backward.  When  we  fail  with 
the  taxis  in  the  usual  position,  we  may  make  the  patient  stand  up, 
and  standing  behind  him,  seize  the  hernia,  and  push  down  with  left 
hand,  and  press  up  with  the  right.  A  hernia  may  thus  be  reduced 
when  it  could  not  have  been  in  the  recumbent  position,  owing,  per- 
haps, to  the  parts  being  put  more  in  the  position  in  which  the 
hernia  was  developed.  If  the  hernia  be  very  large,  or  scrotal, 
the  surgeon,  standing  behind  the  patient,  takes  hold  of  the  tumor 
with  both  hands,  and  pulls  downward,  to  release  the  hernia  from 
around  the  orifice,  and  then  with  the  ends  of  the  fingers  placed  on  the 
fundus,  pushes  gradually  upward,  while  the  body  and  palms  of  the 
hand  make  pressure  downward.  This  failing,  patient  may  be 
turned  on  the  opposite  side  from  hernia,  and  elevated  to  further  assist 
the  taxis  by  position.  The  same  efforts  may  be  again  resorted  to 
in  this  position,  and  will  sometimes  succeed  after  failure  in  the 
other.  These  efforts  must  be  most  gently  and  constantly  continued 
for  fifteen  or  thirty  minutes,  and  these  failing  we  may  resort  to  rup- 
ture. 

Baron  Suiten's  Method,  of  Brussels.  He  feels  for  the  neck  of  the 
sac,  and  then  insinuates  the  ends  of  the  fingers  between  the  sac  and 
the  walls  of  the  orifice,  and  pushes  and  presses  the  ends  of  the  finger- 
nails up  until  he  separates  the  sac  from  its  attachment,  and  then 
returns  the  hernia.  He  is  said  to  have  succeeded  in  nearly  all 
cases,  and  rarely  resorted  to  any  other  for  twenty  years  before  his 
death.  When  there  is  much  gas  or  serum  in  the  sac  it  may  be  let 
out  with  an  exploring  needle,  or  small  trocar.  But  it  is  evident 
that  this  process  should  be  resorted  to  very  cautiously,  and  only 
under  the  following  circumstances : — When  the  hernia  is  large ; 


98  HERNIA. 

not  very  tender ;  of  recent  formation  or  strangulation ;  no  vomit- 
ings having  set  up,  especially  vomitings  from  the  intestines ;  no 
complete  obstruction  of  the  bowels.  When  it  can  be  done  under 
these  circumstances  it  is  a  safe  and  judicious  process,  and  will  be 
attended  with  the  hest  results.  But,  on  the  contrary,  if  the  hernia 
be  small,  and  very  tender,  of  several  days'  standing,  and  stercora- 
ceous  vomitings  have  commenced,  it  ought  not  to  be  thought  of,  as 
the  result  may  prove  fatal,  by  tearing  open  the  sac,  and  letting  out 
the  contents  into  the  abdomen,  bursting  the  intestines,  returning 
the  hernia  unreduced,  making  the  case  worse  for  an  operation. 
Failing  in  all  these,  if  intestinal  vomitings  have  not  set  up, 
we  may  resort  to  the  use  of  adjuvants  to  the  taxis,  putting  pa- 
tient under  chloroform  or  ether,  and  again  trying  the  taxis.  I  have 
often  succeeded  in  this  way,  when  I  could  not  without  the  chloro- 
form. Failing  under  chloroform,  and  patient  not  yet  suffering 
from  intestinal  vomitings  or  hiccough,  with  no  great  pain  or  vio- 
lent distention,  we  may  resort  to  the  use  of  opium  by  the  mouth, 
rectum,  or  hypodermically,  as  seems  best,  in  the  intervals  of  vom- 
iting ;  apply  ice  in  flannels  or  bladders  over  the  tumor,  and  give 
injections  of  warm  or  cold  water,  whichever  is  considered  best;  or 
we  may  give  one  after  the  other,  to  more  effectually  excite  the  peri- 
staltic action  of  the  bowels.  Purgatives  should  not  be  thought  of 
if  there  be  complete  obstruction,  and  they  are  of  doubtful  charac- 
ter in  any  case,  except  as  means  of  assisting  the  diagnosis,  as  we 
have  seen ;  if  the  hernial  contents  be  only  omentum,  the  bowels  are 
not  necessarily  constipated,  and  never,  or  rarely,  obstructed ;  nor 
is  the  patient  in  much  immediate  danger.  The  csecum  or  bladder 
may  also  be  strangulated,  and  obstruction  will  not  be  complete. 
These  efforts,  continued  a  reasonable  time,  have  succeeded  in  my 
hands  when  I  have  failed  without  them.  JBat  when,  and  at  what- 
ever stage  we  find  our  patient  laboring  under  the  following  symp- 
toms, no  further  delay  should  he  permitted,  and  an  operation  re- 
sorted to  at  once :  complete  obstruction,  stercoraceous  vomiting, 
hiccough,  great  distention  of  the  sac,  much  tenderness  over  the 
tumor,  crackling,  or  oedematous  feeling  in  the  tumor,  emphysema, 
and  a  quick,  weak  pulse,  and  hot  skin ;  lastly,  when  the  tumor  is 
seized,  as  in  taxis,  and  you  can  feel  distinctly  the  contents  of  the 
sac  come  to  a  certain  line,  and  then  rebound.  This  last  symptom 
is  enough,  of  itself,  to  stop  all  further  efforts,  and  demands  a  re- 
sort to  an  operation  at  once. 


CHAEACTEES   AND   EELATIONS.  99 

This  may  be  performed  in  three  ways.  Shaving  off  all  hairs, 
and  putting  the  patient  under  chloroform,  the  surgeon  proceeds,  in 
the  first  method,  to  take  up  a  fold  of  integument  as  far  as  he  can, 
and  then  run  his  bistoury  through  it  with  the  back  to  the  sac,  and 
cut  straight  out.  This  incision  may  be  enlarged  upward  or  down- 
ward as  far  as  necessary,  on  a  grooved  director.  The  surgeon  then 
takes  a  pair  of  tooth  forceps,  and  hitches  up  a  small  fold  of  the 
coverings  below,  and  with  the  point  of  the  bistoury  turned  flat,  cuts 
it  open.  Then  taking  the  grooved  director  he  puts  it  through  this 
hole,  and  pushes  it  gently  under  it  as  far,  either  way,  as  the  exter- 
nal incision,  and  raising  it  up,  he  feels,  with  the  right  hand  index 
finger,  for  any  artery,  vein  or  nerve,  that  may  cross  it.  If  there 
is  an  artery  or  vein,  it  ought  to  be  tied  both  sides  of  the  groove, 
and  then  cut,  to  prevent  any  hemorrhage  that  might  obscure  the 
examination  of  the  parts  and  interfere  with  the  further  incision. 
This  being  done,^  another  layer  is  taken  up  and  cut  in  the  same 
way,  until  we  arrive  at  the  sac. 

Now,  at  this  point,  there  is  matter  of  deep  interest ;  and  after 
taking  in  consideration  the  previous  history  of  the  case — all  the 
symptoms  and  the  general  appearance,  as  now  seen  in  the  sac  and 
through  it — he  must  determine  whether  to  open  the  sac  before  cut- 
ting the  stricture,  or  to  cut  the  stricture  outside  of  the  sac,  and 
return  it  without  examining  the  contents.  We  have  fully  dis- 
cussed the  points  under  the  head  of  hernias  in  general,  but  we  will 
repeat  them  here,  as  they  are  of  the  utmost  importance.  Hernia 
large  ;  of  recent  formation  ;  no  great  soreness,  and  no  ecchymosis 
of  the  serous  coverings,  and  stricture  outside  of  the  sac.  In  this 
condition  it  is  thought  safest  to  cut  the  stricture  outside  of  the  sac, 
as  it  does  not  expose  the  peritoneum.  First  performed  by  J.  L. 
Petit,  in  1718,  and  revived  by  Eareton,  in  1750. 

But  if  these  favorable  symptoms  are  not  perfectly  evident,  the 
sac  should  be  opened,  and  I  believe  this  is  the  safest  and  best,  after 
all,  as  we  can  sew  up  the  old  sac  and  make  a  radical  cure,  and  we 
will  be  sure  of  avoiding  returning  the  sac  with  the  contents  still 
adhered  or  strictured,  or  in  a  diseased  or  mortified  condition.  The 
sac  should  be  very  carefully  opened  by  pinching  up  a  small  portion 
with  a  pair  of  forceps  or  a  tenaculum  at  its  lowest  and  most 
prominent  point,  and  then  cut  with  bistoury,  flatwise.  When 
this  is  done,  more  or  less  serum  will  pour  out,  sometimes  as  clear 
as  water,  but  generally  about  the  color  of  ordinary  urine,  making 


100  HERNIA. 

the  operator  think  he  has  penetrated  the  bladder,  if  he  is  inexperi- 
enced. This  serum  is  sometimes  mixed  with  blood,  pus  and  fecal 
matter,  and  as  I  saw  in  one  case,  watermelon  seed.  When  we 
find  pus  and  foreign  bodies  in  the  sac,  we  may  be  sure  the  intestines 
have  been  ruptured,  and  it  would  not  be  safe  to  return  the  intes- 
tine. When  this  is  the  case,  having  fully  exposed  the  contents 
and  carefully  examined  them,  to  see  if  any  portion  is  gangrenous, 
or  any  holes  oozing  out  fecal  matter,  the  bowels  must  not  be  re- 
turned, and  I  cut  the  stricture  outside  of  the  sac  with  a  dull  knife, 
and  turn  the  sac  so  as  to  entirely  relieve  the  stricture,  but  not 
to  cut  the  line  of  adhesion  of  the  sac  to  the  orifice,  lest  fecal 
matter  may  burrow  along  this  incision  or  it  may  give  way  and 
the  intestine  slip  back  so  as  to  pour  its  contents  into  the  abdomen. 
If  the  contents  are  in  a  state  of  hopeless  gangrene,  or  sphacelated, 
they  should  be  cut  off  with  a  pair  of  scissors,  and  an  artificial 
anus  formed.  But  if  the  contents  have  only  a  few  spots  of  ecchy- 
mosis,  or  holes,  the  stricture  may  be  cut  and  the  contents  still  left 
in  the  open  sac,  after  the  process  of  Gerard,  with  a  simple  dressing 
and  compresses.  In  this  stricture  the  holes  may  close,  and  the 
contents,  in  a  week  or  ten  days,  return  sound.  Gerard  recom- 
mends this  method  in  all  cases  where  there  is  much  congestion, 
and  gives  very  favorable  statistics  of  his  cases.  At  least,  the 
bowel  should  not  be  returned  if  the  operator  has  any  doubt  about 
its  soundness.  When  it  is  completely  dead,  or  to  speak  more  pro- 
fessionally, sphacelated,  it  must  be  cut  off,  up  to  the  sound  tissues, 
with  a  pair  of  scissors,  and  left  to  nature  to  form  an  artificial 
anus.  I  remember  operating  on  a  sailor,  in  1863,  a  patient  of 
the  late  Dr.  N.  D.  Labadie,  of  Galveston,  for  a  scrotal  hernia, 
and  when  I  cut  down  to  the  sac,  I  found  the  bowel  mortified,  and 
also  the  testicle  perfectly  black  and  cold;  I  cut  it  off  and  left  the 
wound  open,  and  the  patient  appeared  to  do  well  for  four  days, 
when  acute  peritonitis  set  in  and  the  patient  died.  I  believe  the 
inflammation  spread  by  continuity  of  tissue,  down  the  cord,  and 
thus  involved  the  deep  tissues.  The  artificial  anus  continued  to 
freely  discharge  fecal  matter.  This  case  was  purely  lost  for  want 
of  timely  aid.  I  operated  immediately  on  seeing  his  condition, 
but  was  too  late.  In  the  case  I  mentioned  before,  of  Negro  man,  B., 
who  had  a  very  old  hernia,  that  had  often  been  strangulated  and 
relieved  by  his  attending  physicians,  two  of  whom  were  present 
when  I  operated,  I  found  the  sac  much  diseased,  but  as  I  had  to 


CHARACTEES   AND   RELATIONS.  101 

operate  by  a  tallow  candle,  in  an  open  cabin,  I  could  not  examine  my 
patient  well,  so  I  returned  the  sac  and  the  patient  sank  that  night. 
Next  morning  I  opened  the  wound  and  examined  it,  and  as  I  said 
before,  found  a  watermelon  seed  in  the  sac,  and  quite  a  number  in 
the  peritoneal  cavity,  and  some  pus  and  fecal  matter.  There  were 
three  holes  in  the  intestines,  one  large  enough  to  discharge  the  seed. 
The  other  portions  were  deeply  ecchymosed,  but  in  a  condition  to 
have  been  restored,  if  the  holes  had  not  been  formed.  I  believe 
these  were  produced  by  long  efforts  at  the  taxis.  Upon  further 
inspection,  I  found  the  descending  colon  attached  to  its  folds  in 
three  places,  looking  like  the  scars  of  a  burn,  showing  it  had  been 
strangulated  at  three  different  times,  and  inflammation  had  pro- 
gressed to  adhesion  before  reduction.  I  also  remember  a  case,  in  a 
post-mortem  after  typhoid  fever — a  case  of  old  standing  hernia — in 
which  the  omentum  was  attached  to  the  ilium,  and  two  adhesions 
between  different  portions,  leaving  scars  like  a  burn. 

I  believe  adhesions  of  this  kind  are  of  frequent  occurrence,  and 
are  the  cause  of  colic  and  symptoms  of  invagination,  in  cases  of 
hernia.  I  remember,  in  1871,  being  called  by  Dr.  Goldman,  of 
Galveston,  to  see  a  patient  of  his,  a  distinguished  gentleman  of 
Galveston,  who  suffered  from  severe  colic  pains,  with  nausea  and 
vomitings,  for  nearly  a  week  after  the  reduction  of  the  hernia, 
causing  very  alarming  symptoms,  but,  by  anodynes  and  refrige- 
rants, he  made  a  good  recovery.  These  were  all  cases  of  inguino- 
scrotai  hernia,  of  long  standing.  It  is  thus  evident  that  the 
surgeon  cannot  be  too  careful  in  his  examination  of  the  sac  and 
its  contents  before  he  returns  it,  and  if  there  be  any  doubt  about 
the  case,  Gerard's  method,  of  leaving  the  entire  sac  and  contents 
still  in  position  after  cutting  the  stricture  and  applying  a  com- 
press to  keep  it  from  enlarging  should  be  adopted.  This  plan  I 
have  never  adopted,  but  think  well  of  it,  and  believe  it  is  better 
than  making  an  artificial  anus  at  once;  which  may  thus  be  avoided. 
When  the  bowels  are  in  a  condition  to  be  returned,  it  ought  to  be 
done  at  once ;  wound  cleansed  well,  and  then  brought  neatly  to- 
gether With  silver  wire. 

Thb  plan  I  have  adopted  introduces  the  double  spear-pointed 
needle,  used  for  the  radical  cure  of  hernia,  as  seen  in  Plate  iv,  page 
49.  I  put  the  threaded  end  down  to  the  edge  of  the  peri- 
toneum, including  about  one-third  of  an  inch,  and  then  push  it 
out,  close  to  the  line  of  incision,  to  the  ■  external  surface.     The 


102  ,  HERNIA. 

needle  is  tlien  released  by  unthreading  it,  and  needle  taken  out, 
leaving  the  wire  in  situ.  The  other  end  of  the  wire  is  then  threaded, 
and  needle  carried  through  the  opposite  side  from  the  peritoneum 
externally.  Two,  three  or  four  wires  are  then  put  in,  or  as  many 
as  is  needed  to  completely  close  the  orifice ;  when  they  are  all  put 
in  place  the  wound  is  closed  by  tightening  and  tying  them  firmly, 
making  an  interrupted  suture  of  silver  wire.  When  speaking  of 
making  the  incision,  I  stated  I  always  made  my  cuts  straight, 
for  the  reason,  I  could  better  bring  them  together.  I  have  used 
this  method  in  two  cases,  the  only  ones  I  have  had  since  the  in- 
vention of  my  needle ;  both  were  perfect  cures,  and  had  no  symp- 
tom of  peritonitis  while  under  treatment,  and  but  little  suppura- 
tion. I  used  simply  morphine  and  sugar  of  lead  lotion  to  the 
wound,  covered  with  cotton  batting  and  with  oiled  silk.  In  the  first 
case  I  tried  to  pass  the  wires  in  with  an  ordinary  surgeon's  needle, 
but  could  not  do  it,  and  I  sent  home  and  got  my  hernia  needle,  and 
put  the  wires  in  to  suit  me,  and  the  result  was  all  I  could  ask.  I 
have  already  mentioned  two  other  cases,  McKim  Lea  and  a 
butcher,  of  Galveston,  where  the  wound  was  sewed  up  with  this 
needle  in  the  same  way,  but  was  not  put  into  the  peritoneum,  as  it 
had  closed  fast  around  the  strangulated  parts  that  were  cut  oflf. 
Both,  as  stated  before,  recovered. 

Before  leaving  the  subject  of  the  operation  by  incision  for  the 
reduction  of  a  strangulated  hernia,  I  will  mention  certain  pecu- 
liarities attending  the  operation.  First,  in  the  funiculatic  hernia 
(or  "encysted,"  or  "impacted,"  as  usually  called),  the  operator 
will  meet  with  three  folds  of  the  peritoneum  before  reaching  the 
contents,  and  the  testicle  will  be  in  one  sac  and  the  hernial  contents 
in  another,  and  the  testicle  will  be  anterior  to  the  hernia.  The 
operator  ought  always  to  bear  this  in  mind,  and  it  may  be  well  to 
diagnose  this  condition  by  the  symptoms  before  given.  If  it  be 
the  oblique  inguino-scrotal  hernia  of  congenital  formation,  there 
will  be  only  one  sac,  as  we  have  seen,  and  the  contents  of  the  sac 
will  lie  over  and  with  the  testicle  in  the  same  covering  (see  Fig.  34, 
page  90).  In  hernia  by  diverticulum,  you  will  find  a  sac  protrud- 
ing from  the  body  of  the  intestine  as  an  aneurismal  sac  on  an  artery 
(see  example,  Plate  iii,  E,  page  17).  This  must  not  be  opened,  but 
a  ligature  put  in  at  its  base  and  firmly  tied,  and  the  ligature  be 
brought  out  at  the  incision  and  there  confined  until  it  cuts  out  and 
effects  a  cure,  the  wound  being  firmly  closed  around  it  as  before. 


RADICAL   CURE   OF    REDUCED    INGUINAL   HERNIA 


103 


The  forms  of  infundihulatic  and  ligamentatic,  in  the  female,  are 
treated  in  the  same  way  as  the  male.  The  only  difference  being 
that  the  round  ligament  takes  the  place  of  the  spermatic  cord,  and 
the  labial  form  that  of  the  scrotal  in  the  male. 


Pig.  35. 


THE   RADICAL   CURE   OF   REDUCED    INGUINAL   HERNIA. 

Having  reduced  the  hernia,  and  the  patient  recovering  from  the 
inflammation,  it  then  becomes  a  subject  of  consideration  whether 
we  shall  resort  to  any  means  to  effect  a  radical  cure,  or  leave  our 
patient  to  a  palliative 
treatment  with  bandages 
and  trusses.  We  do  not 
propose  to  repeat  what 
we  said  under  "  General 
Hernia,"  but  to  make  re- 
marks upon  the  principle 
to  be  adopted  in  curing 
inguinal  hernia  of  the  ob- 
lique variety,  especially  the  congenital.  Where  the  two  rings  are 
not  dragged  into  one,  we  may  effect  a  cure  by  a  well-fitting  truss, 
with  little  more  than  ordinary  pressure.  The  French  truss.  Fig. 
35,  and  Pomeroy's  double-pad  truss  are  among  the  best;  Shel- 
don's next ;  Sherman's  patent.  Fig.  36,  is  perhaps  the  strongest,  or 

Fig.  36. 


French  Truss. 


Sherman's  Truss. 


Hood's,  with  two  pads,  one  for  keeping  up  the  hernia,  and  the  other 
for  supporting  the  opposite  side  (See  Fig.  20,  page  33).  This 
should  be  worn  constantly,  night  and  day,  if  possible,  and  if  it 
cannot  be  worn  at  night,  it  should  be  put  on  always  before  getting 
out  of  bed  in  the  morning ;  should  not  be  taken  off  while  in  bath, 


104  HERNIA. 

or  especially  while  swimming.  Those  who  swim  or  take  baths 
should  provide  themselves  with  Seeley's  or  Riggs'  trusses,  cov- 
ered with  hard  rubber,  or  celluloid  (see  Fig.  8,  page  27).  They 
make  them  of  all  patterns,  but  coat  the  springs  and  pad  with  hard 
rubber ;  in  fact,  the  pad  is  made  of  hard  rubber,  water  blown  to 
the  desired  shape  and  size.  This  india-rubber  or  celluloid  coat- 
ing is  specially  applicable  to  warm  climates,  and  persons  working 
in  furnaces,  blacksmith-shops,  and  other  places  where  laborers  per- 
spire freely.  They  will  last  longer,  and  be  more  cleanly  than  any 
other,  except  those  thoroughly  galvanized.  No  leather  pads  or 
leather  coverings  are  suitable  to  warm  climates. 

We  may  often  effect  cures  in  oblique  inguinal,  scrotal,  or  labial 
hernia,  by  the  truss,  because  we  have  a  surface  to  press  on,  and 
pressure  causes  the  serous  coats  to  unite  and  close  the  opening. 
No  cure  may  be  expected  in  cases  of  direct  inguinal  hernia  by  the 
truss. 

The  other  plans  for  cure,  that  are  alone  adapted  to  this  variety 
and  that  of  femoral,  are  all  the  plugging  and  invaginating  pro- 
cesses which  we  have  mentioned  in  the  section  on  hernia  in  general, 
as  Gerdy's,  Wurtzer's,  Rothmund's  and  Meyer's.  As  these  have  been 
almost  entirely  abandoned  by  surgeons,  we  shall  not  speak  more 
of  them  here.  Next  in  order  is  Prof.  Agnew's,  a  combination  of 
plugging  and  ligation.  His  success  has  been  worthy  of  further 
continuance,  and  is  far  superior  to  any  of  the  others  just  men- 
tioned, but  need  not  be  repeated  here,  any  further  than  to  say  it  is 
only  applicable  in  oblique  inguinal  and  femoral,  and  can  do  no  good 
in  any  other.  This  is  quite  an  advance  over  the  others,  but  not 
preferable  to  Dr.  John  Wood's,  of  London,  which  also  has  prece- 
dence as  to  date,  he  having  operated  on  sixty-two  cases  before 
1862,  and  Prof.  Agnew  commenced  his  operations  about  that  time. 
Dr.  John  Wood's  process  we  have  given  in  full  under  general  her- 
nia, and  need  not  repeat  here,  but  will  say  it  is  adapted  peculiarly 
to  inguinal,  scrotal,  and  labial  hernias,  but  not  alone  to  these  varie- 
ties, as  his  process  by  pins  is  suitable  especially  to  umbilical  and 
ventral,  as  well  as  inguinal  hernias.  His  process  by  pins  is  i^r 
better  than  Beckwith's  with  needles  and  hare-lip  sutures.  This 
process  scarcely  deserves  the  notice  I  have  given  it ;  but  as  other 
experimenters  might  try  it,  I  did  not  think  this  treatise  would  be 
complete  without  it.  To  advance  in  any  science  one  should  be 
familiar  with  all  that  others  have  both  done  and  attempted  to  do. 


FEMORAL  HERNIA  IN  MALE  AND  FEMALE.        105 

Failures  are  as  valuable  as  successes,  and  anything  that  carries 
plausibility  with  it  should  be  noticed.  There  is  no  question  in  my 
mind,  but  that  the  report  of  Wurtzer's  operation  gave  a  new  im- 
petus to  the  study  of  the  radical  cure  of  hernia,  that  has  brought 
forth  such  good  results  that  we  may  hope  to  cure  all  cases. 

The  next  improvement,  as  we  think,  is  the  process  of  Dr.  Thomas 
"Wood,  of  Cincinnati;  but  as  he  only  reports  three  cases,  httle  can 
be  said  about  it ;  and  as  he  has  not  illustrated  his  process,  I  do  not 
believe  any  one  fully  understands  it.  I  will  say,  however,  that 
notices  of  his  process  gave  the  author  aid  in  inventing  his  needle, 
though  I  never  saw  the  original  article  until  recently,  when  I 
found  it  in  the  library  of  the  American  Medical  Association,  vol. 
IV,  in  Dr.  W.  B.  Atkinson's  ofl&ce.  I  have  most  of  the  volumes, 
but  this  number  was  burned  up,  and  is  very  scarce  ;  I  do  not  know 
that  it  can  be  found  anywhere  else.  I  will  not  repeat  what  I  have 
said  before,  nor  re-quote  him  here ;  see  page  46  and  re-read  it. 
His  process  seems  to  me  to  be  only  applicable  to  oblique  inguinal 
hernia,  where  the  rings  are  not  interfered  with,  and,  consequently, 
limited  to  a  comparatively  few  cases. 

The  author's  method  is  well  adapted  to  inguinal  hernia,  oblique, 
or  direct,  as  well  as  all  others  of  external  character.  We  refer  to 
Plate  IV,  page  49,  for  illustration,  and  copy  in  full  the  case  of 
Josiah  Overton,  from  the  Galveston  Medical  Journal,  as  this 
was  the  first  case  operated  on  with  the  present  needle,  and  accord- 
ing to  the  method  adopted  then,  and  the  one  used  June  26th, 
1872,  at  Philadelphia  Insane  Asylum.  See  report  of  cases,  page  58 
(Josiah  Overton,  case  of  reducible  inguinal  hernia,  operated  on 
by  me  at  City  Hospital,  by  the  subcutaneous  silver-wire  suture, 
performed  with  the  double  spear-pointed,  semi-circular  needle). 

As  we  stated  under  general  hernia,  we  think  this  process  adapt- 
able to  all  cases,  and  attended  with  scarcely  any  risk.  Read  again 
the  report  of  the  cases  treated. 

FEMORAL  HERNIA  IN  MALE  AND  FEMALE. 

Symptoms. — The  general  symptoms  are  the  same  as  in  all  her- 
nias, but  it  may  be  readily  made  out  by  its  position.  It  passes 
always  under  the  ilio-pubio  ligament,  and  usually  to  the  inner 
side,  or  as  I  usually  say,  to  the  median  side,  or  middle  side,  of  the 
femoral  vein  and  nerve,  and  in  its  sheath,  burrowing  under  the 
8 


106  HEENIA. 

ligament,  and  pushing  the  fascia  propria  crurialis  (septum  crura- 
bile)  before  it,  forming  its  own  sac  out  of  a  depression  of  the  peri- 
toneum, or  passing  on  down  to  the  inner,  or  median  side,  comes  out 
below  the  falciform  process  of  the  fascia  lata  of  the  thigh,  in  the 
upper  portion  of  the  femoral  triangle  (Scarpa's),  into  the  saphenous 
opening,  and  pressing  before  it  the  cribriform  fascia,  makes  its 
appearance  outward  in  the  femoral  triangle,  and  turns  upward  to 
the  ilio-pubic  ligament.  t 

The  tumor  is  usually  small  in  comparison  with  inguinal  hernia, 
and  is  often  found  in  its  incomplete  form,  the  hernial  knuckle  lying 
in  the  canal  between  the  fascia  propria  and  cribriform  fascia,  and 
may  be  mistaken  for  an  inflamed  lymphatic  gland,  a  psoas  abscess, 
an  enlarged  varicose  vein,  or  an  aneurism  of  the  femoral  artery. 
These  can  be  diagnosed  by  reviewing  the  tables,  pp.  91,  92.  Some- 
times the  sac  forms  under  the  sheath  of  the  vein,  artery  and  nerve, 
and  divides  them,  and  again  it  passes  between  the  nerve  and  liga- 
mento-iliac  ligament  (Hay's  ligament),  to  the  outside  of  the  femo- 
ral sheath,  and  again  it  passes  through  the  ligamento-pubic  liga- 
ment (Gibernat's  ligament),  and  passes  down  on  the  ramus  of  the 
pubis.  These  peculiar  positions  should  be  borne  in  mind  when  we 
attempt  to  incise  for  strangulation. 

Causes  are  the  same  as  those  of  inguinal  hernia,  general  and 
special.  The  principal  predisposing  cause  is  the  relaxation  of  the 
femoral  opening,  as  the  patulence  of  the  spermatic  cord  in  con- 
p;enital  ing-uinal  hernia.  Sex  seems  also  to  have  some  influence 
on  this  hernia,  as  it  is  as  common,  if  not  more  so,  in  the  female 
than  in  the  male,  and  is  more  common  in  females  than  inguinal, 
and  next  to  umbilical,  according  to  my  experience,  umbilical  be- 
ing the  most  common  of  all  hernias  in  females,  and  femoral  next. 
It  rarely  occurs  before  the  eighth  year,  while  inguinal  and  umbili- 
ical  are  often  congenital.  The  tumor,  when  not  strangulated,  can 
easily  be  reduced,  and  leaves  a  hole  the  little  finger  can  be  pressed 
into.  This  form  of  hernia  is  more  liable  to  strangulation,  owing  to 
its  anatomical  relations,  and  the  confined  space  through  which  it 
has  to  pass,  and  the  impossibility  of  the  neck  becoming  much  di- 
lated or  expanded. 

Diagnosis,  from  inguinal  hernia,  is  very  plain,  as  it  always 
comes  out  below  the  ilio-pubic  ligament,  and  never  above.  I  have 
entirely  excluded  all  such  names  as  inguino-crural  hernia  from  this 
treatise,  as  there  cannot  be  such  a  thing,  taken  anatomically ;  and 


PEMOEAL  HEENIA  IN  MALE  AND  FEMALE.        107 

our  representations  should  be  founded  as  mucli  as  possible  upon 
anatomical  relations.  I  have  also  defined  the  variety  that  comes  out 
immediately  at  the  saphenous  opening,  crural,  from  cms,  cruris 
(see  plate  i,  Fig.  1,  h,  page  13),  and  that  which  forms  lower  down 
in  the  femoral  triangle,  femoral. 

This  is  truly  an  anatomical  division,  and  will  be  strictly  adhered 
to  in  this  treatise,  as  will  appear  in  our  division  of  the  body. 
When  the  hernia,  passing  under  the  femoral  sheath,  reaches  the 
femoral  region  before  it  begins  to  protrude,  it  is  called  emphati- 
cally femoral  hernia,  from  femur,  the  thigh.  See  plate  i,  Fig.  1, 
I,  page  13. 

Prognosis  is  unfavorable  in  these  cases,  as  it  is  so  liable  to 
strangulation,  and  so  difficult  to  keep  up  by  a  truss,  being  much 
more  difficult  to  properly  fit  a  truss  on.  Any  tenderness  in  this 
region  should  be  at  once  attended  to,  and  no  impaction  or  incar- 
ceration of  the  intestine  should  be  permitted.  My  experience  in 
this  variety  would  lead  me  to  believe  that  the  contents  of  the  sac 
in  most  femoral  hernias  is  omentum-epiplocele,  or  in  the  female, 
ovarian.  Where  the  hernia  is  epiplocele,  it  will,  when  strangu- 
lated, suppurate,  and  it  is  next  to  impossible  to  distinguish  it  from 
psoas  abscess,  unless  by  its  previous  history.  This  hernia  is 
usually  slowly  formed,  rarely  ever  suddenly,  and  hence  the  still 
greater  difficulty  in  distinguishing  it  from  a  suppurating  bubo,  or 
an  abscess,  and  its  long  canal  does  not  allow  of  much  fluctuation  in 
coughing  or  straining,  and  this  may  be,  and  often  is  entirely  sup- 
pressed in  strangulated  femoral  hernia.  Spontaneous  cures  are 
sometimes  made  of  these  hernias  from  suppuration,  where  the 
omentum  alone  is  involved.  I  remember  one  case  in  particular  in 
the  City  Hospital,  1866,  that  made  a  complete  and  effectual  cure. 
But  in  the  same  year  there  was  a  most  disgusting  and  deplorable 
case  of  rupture  of  the  caecum  in  a  femoral  hernia,  that  nothing  could 
be  done  for;  after  his  admission  the  fecal  matter  poured  out  below 
the  saphenous  opening,  and  burrowed  down  even  to  the  lower  third 
of  the  thigh,  dissecting  up  and  separating  all  the  muscles.  Patient 
finally  died,  from  pain  and  exhaustion. 

Coverings  of  femoral  hernia  depend  upon  the  diff"erent  varieties 
we  have  given,  but  of  ordinary  complete  femoral  hernia,  are  from 
within  out:  sac  (1),  or  peritoneal  covering;  crural  septum  (2)  or 
fascia  propria  crurialis ;  crural  sheath  (3) ;  cribriform  fascia  (4) ; 
superficial  fascia  (5),  and  skin  (6). 


108  HERNIA. 

Its  relations  and  boundaries  are,  above  ilio-pubic  ligament, 
below  body  of  os  pubis,  and  sometimes  above  the  femoral  sbeatb, 
and  again  below  it,  but  usually  to  the  median  side.  Median  or 
inner  side,  ligamento-pubic  ligament  (Gibernat's) ;  outer  side,  liga- 
mento-iliac  ligament  (Hay's).  The  special  forms  will  be  recog- 
nized by  their  names  as  follows  : — 

1.  Pectenial  crural  or  hernia  of  Cloque,  where  the  hernia  after 
passing  down  turns  inward  under  the  femoral  vessels,  and  lies  on 
the  pectenius  muscle. 

2.  Hernia  through  the  ligamento-pubic  ligament  (Gibernat's),  or 
hernia  of  Lougier. 

3.  Hernia  hy  diverticulum  through  the  cribriform  fascia  (Hessel- 
bach's  hernia).  It  assumes  a  lobulated  form,  by  coming  out  at 
several  openings  in  the  cribriform  fascia. 

4.  Hernia  by  diverticulum  through  the  superficial  fascia  or  hernia 
of  Cooper.     Lobulated  like  the  last. 

5.  Hernia  external  to  \he  femoral  vessels,  or  that  described  by 
Partridge. 

Usually  the  femoral  vein  lies  to  the  outer  side  of  the  hernia, 
and  almost  immediately  connected  with  it,  only  separated  by  a 
septum  of  the  crural  sheath. 

The  epigastric  artery  is  above  and  to  its  outer  side.  The  sper- 
matic cord  lies  nearly  immediately  above  it,  on  the  median  side. 

The  obturator  artery,  when  it  arises  from  the  external  ihac,  com- 
mon femoral,  or  epigastric  artery,  instead  of  its  normal  origin  from 
the  internal  iliac,  descends  to  the  outer  side  of  the  crural  ring,  to 
reach  the  obturator  foramen,  and  rarely  passes  along  the  slim  border 
of  the  ligamento-pubic  ligament  (Gibernat's),  where  it  would  almost 
completely  encircle  the  neck  of  the  sac. 

Where  the  hernia  escapes  to  the  outer  side  of  the  femoral  sheath 
(Partridge's  hernia),  the  circumflex  iliac  artery  lies  to  the  outer 
side  of  the  sac. 

TREATMENT  OF   FEMORAL   HERNIA. 

The  palliative  treatment  consists  in  a  truss  with  a  fusiform  pad 
and  a  peritoneal  strap  (see  Fig.  21,  page  33).  The  spring  extends 
around  to  the  spine,  and  there  it  has  connected  with  it  a  leather 
strap  or  band,  carried  around  the  body  above  the  opposite  hip,  and 
fastened  to  the  pad  in  front.  The  perineal  strap  keeps  it  in  place, 
and  it  is  peculiarly  useful  in  those  who  have  to  make  quick  and 


TREATMENT   OF   FEMORAL   HERNIA.  109 

varied  motions,  as  marines,  cavalrymen,  sailors  and  laborers. 
Sudden  movements  or  twisting  of  the  body  do  not  relinquish  its 
grasp  upon  the  orifice.  Hirsch's  elastic  trusses  (Fig.  13,  page  29), 
are  also  useful  in  these  cases,  and  when  well  put  on,  are  probably  more 
pleasant  to  the  wearer  than  any  other,  and  have  the  advantage  of  be- 
ing able  to  be  worn  at  night  as  well  as  day,  which  is  so  important  in 
effecting  a  radical  cure.  We  cannot  hope  for  much  success  in  a  radical 
cure  in  this  hernia,  owing  to  the  juxtaposition  of  the  femoral  vein 
and  artery  on  the  outside,  and  the  spermatic  cord  on  the  median  side, 
which  prevent  our  making  any  severe  pressure,  or  pressure  of  any 
extent;  we  must,  therefore,  rely  on  one  or  the  other  of  the  following 
processes :  Wood's,  with  wire ;  Jamison's  or  Davies',  with  plugs 
made  out  of  flaps ;  Gross'  direct  method,  or  the  author's.  All  of 
which  are  adapted  to  this  form  of  hernia. 

In  using  the  author's  process  in  femoral  hernia,  particluar  atten- 
tion should  be  paid  to  the  following :  Bowels  should  be  well  moved 
before  operating;  bladder  emptied;  the  needle  should  always  be 
started  in  first  position  (see  Plate  i.  A,  page  49),  from  the  median 
side,  and  in  second  position,  should  be  careful  not  to  inclose  the 
femoral  vein,  artery  or  nerve ;  the  ligature  should  be  put  up  as  high 
and  as  close  to  Poupart's  ligament  as  possible,  and  others  put  lower 
down  until  completely  closing  the  orifice.  The  needle  should  be  well 
curved  in  the  median  side,  so  as  not  to  include  the  sheath  of  the 
vein  and  artery.  In  any  of  the  anomalies,  I  think  the  direct 
method  is  the  safest,  and  should  be  resorted  to  without  fear  or 
dread,  and  the  incision  closed  with  silver  wire,  carefully  put  in,  so 
as  not  to  involve  any  of  the  important  relations  described. 

Herniotomy. — Gay's  method.  He  makes  an  incision  about  an 
inch  in  length  on  the  median  [inner)  side  of  the  tumor,  near  the 
neck  of  the  sac ;  then  cautiously  divides  the  various  tissues,  until 
a  concealed  bistoury  can  be  inserted  between  the  neck  of  the 
sac  and  the  inner  margin  of  the  crural  ring.  The  edge  of  the 
knife  is  then  turned  towards  the  pubis,  when,  by  projecting  the 
blade,  the  stricture  is  cut.  This  was  the  popular  method  of  Sir 
William  Ferguson  and  he  rarely  used  any  other.  He  used 
instead  of  the  bistoury  cache,  the  common  hernia  knife. 

Obturator  Hernia. — This  rare  form  was  first  described  by 
Garengent.  The  hernia  passes  through  the  obturator  foramen 
(see  Plate  i,  h,  page  15)  and  comes  out  and  forms,  in  some  cases,  a 
round  tumor  in  the  femoral  triangle,  though  in  other  instances  not 


110  HERNIA. 

the  least  tumor  has  been  seen  or  felt,  it  being  covered  up  with 
the  adductor  muscles.  It  is  more  common  in  females  than  males, 
dependent  on  the  increased  size  of  the  pelvis  and  the  enlargement 
of  the  uterus  in  pregnancy,  or  the  pressure  of  an  ovarian  tumor. 
The  sac  (which  usually  contains  the  bowels)  is  small.  It  is  gradu- 
ally developed.  It  is  often  complicated  with  crural  or  femoral 
hernia,  and  sometimes  it  is  double,  occurring  in  both  sides  in  the 
same  patient,  as  reported  by  Hilton.  Its  position  may  usually  be 
defined  by  the  femoral  vessels,  as  it  lays  behind  and  a  little  to  the 
inner  side,  and  under  the  pectineus  muscle,  and  outer  side  of  the 
tendons  of  the  adducter  longus  muscle. 

The  symptoms  are  those  common  to  other  hernias,  and  when  it 
can  be  seen  and  felt  is  easily  made  out,  but  when  it  cannot  be  seen 
or  felt,  we  may  be  governed  by  the  nature  and  seat  of  pains,  and 
the  general  symptoms  of  strangulated  hernia. 

The  Causes. — Independent  of  those  that  are  common  to  hernias 
which  we  have  just  given,  are,  pressure  of  the  womb  and 
ovarian  tumors,  there  may  be  added,  in  the  female,  anteversion  and 
prolapsus  of  the  womb. 

It  is  diagnosed  from  femoral  hernia  by  its  position  in  relation 
to  the  femoral  vessels.  In  femoral  the  hernial  sac  is  anterior  or 
over  the  vessels,  while  in  obturator  it  is  posterior  or  under. 
When  no  tumor  is  perceptible,  the  hernia  may  be  diagnosed 
by  the  following  symptoms,  assisted  by  the  general,  as  given 
above:  1.  The  patient  has  frequently,  before,  felt  colicky  pain 
in  the  pelvic  region,  suddenly  relieved  by  something  slipping 
away,  2.  Strangulation  is  often  preceded  by  severe  pain  in 
the  upper  portion  of  the  thigh.  3.  Cramps  of  the  abdominal 
muscles  more  than  pain  in  the  abdomen,  produced  by  reflection  of 
the  obturator  nerve.  4,  Pain  in  the  course  of  the  obturator  nerve, 
considered  by  Houship  very  significant,  and  is  increased  by  rotat- 
ing the  thigh  outward,  thus  putting  the  obturator  muscle  on  the 
stretch,  thereby  compressing  and  irritating  the  inflamed  neck  of 
the  sac,  5,  Pain  may  be  elicited  by  pressure  on  the  one  side,  and 
not  the  other,  unless  (which  is  very  rare)  the  hernia  be  double,  along 
the  canal  of  the  obturator  outlet.  6.  Pain  may  be  elicited  by 
pressing  on  the  pelvic  side  through  the  vagina  or  rectum. 

Treatment. — The  taxis  should  be  tried,  but  if  this  fail,  an 
exploratory  incision  should  be  made  downward  from  the  ilio-pubic 
ligament,  about  three  inches  in  extent  and  outside  of  the  femoral 


INFERIOR   HERNIA   OF    THE    PELVIC    REGION.  '    111 

vessels,  dividing  the  pectineus  muscle,  and  cutting  in  two  the 
obturator  muscle  carefully,  or  tearing  the  muscles  with  the  handle 
of  the  scalpel  or  director.  Below  this  the  hernial  sac  will  be  seen. 
The  stricture  should  then  be  carefully  divided  from  below  upward. 

Mr.  Burkett  gives  the  history  of  twenty-five  cases  of  obturator 
hernia,  as  follows : — 

In  fourteen  cases  the  nature  of  the  disease  was  not  discovered 
until  death.  In  one  case  the  symptoms  disappeared  without  treat- 
ment. Ten  cases  were  recognized  during  life,  and  were  submitted 
to  treatment;  four  recovered  and  six  died.  The  taxis  succeeded  in 
one  case.  Herniotomy  was  practiced  in  six  cases;  three  recovered 
and  three  died.  Gastrotomy  was  performed  in  one,  but  the  patient 
died.  An  artificial  anus  was  formed,  but  the  patient  died  the  day 
after,  from  gangrene.  I  think  this  is  a  very  rare  form  of  hernia,  as 
I  have  never  seen  a  case. 

INFERIOR   HERNIA   OF    THE    PELVIC    REGION. 

(a.)  Perineal  Hernia. — The  tumor  protrudes  in  the  peritoneum, 
and  usually  appears  between  the  prostate  gland  and  the  rectum  in 
the  male,  and  between  the  rectum  and  vagina  in  the  female,  but 
occurring  on  one  or  the  other  side  of  the  anus.  The  contents  are 
usually  the  intestine,  and  it  is  easily  reduced.  It  is  more  common  in 
the  female  than  the  male,  but  the  symptoms  are  the  same — a  fullness 
and  bearing-down  sensation  in  the  pelvis.  The  tumor  may  be  easily 
felt  from  the  rectum,  and  in  females  from  the  rectum  and  vagina.  The 
causes  are  pressure  at  stool,  falls  and  injuries  in  this  region;  and  in 
females,  pregnancy  and  ovarian  tumors.  The  diagnosis  is  very 
easy,  and  it  can  hardly  be  mistaken  for  any  other  tumor,  though  a 
retroverted  womb  might  give  some  trouble  to  the  inexperienced. 

Treatment. — It  can  be  kept  in  the  pelvis  with  a  truss  of  Hirsch's, 
showm  in  Fig.  11,  page  29,  or  with  Seeley's  hemorrhoidal  truss, 
slightly  modified  by  enlarging  its  point  to  the  shape  of  a  glass 
speculum.  It  may  also  be  kept  up  with  a  compress  and  a  T 
bandage. 

Radical  Treatment. — Direct  incision  should  be  resorted  to  at 
once,  and  the  sac  well  sewed  up  with  silver  wire.  This  is  often 
done  in  pigs,  and  I  never  knew  one  to  die  from  it.  It  is  safe,  and 
if  well  done,  will  make  an  efi"ectual  cure  and  save  your  patient  from 
a  great  deal  of  trouble  and  pain.     The  coverivgs  are  only  the  skin, 


112  HERNIA. 

superficial  fascia  and  peritoneum.  The  point  of  stricture  is  the 
deep  peritoneal  fascia. 

The  author's  process  is  also  adaptable  to  the  radical  cure  of  this 
hernia,  care  being  taken  to  well  curve  the  needle  so  as  not  to 
catch  any  fold  of  the  rectum  or  bladder  in  the  male,  or  the  vagina 
and  rectum  in  the  female,  which  can  be  easily  done. 

(b.)  Pudendal  Hernia — or  hernia  in  the  lower  portion  of  the 
labia.  It  can  only  occur  in  the  female,  and  descends  between  the 
ramus  of  the  ischium  and  the  vagina  to  the  lower  portion  of  one  of 
the  labia  majora. 

Symptoms. — It  forms  a  rounded  tumor — is  easily  reduced; 
sometimes  of  considerable  size;  is  not  often  strangulated;  has 
usually  intestine,  but  may  be  vesicocele,  from  the  inclusion  of 
the  bladder,  which  can  be  ascertained  by  the  use  of  the  catheter  to 
draw  off  the  water,  and  the  finger  in  vagina.  It  is  usually  diag- 
nosed from  inguino-labial  by  its  position  at  the  lower  part  of  the 
labia,  by  its  round  form  instead  of  the  pyriform  shape  of  the  inguino- 
labial,  and  from  its  being  parallel  to  the  axis  of  the  vagina,  and 
from  femoral  hernia  from  its  position  along  the  ramus  of  the 
ischium — this  alone  being  external  to  the  sac  in  pudendal,  and  in- 
ternal in  case  of  crural  hernia — and  from  other  tumors,  such  as 
abscesses  in  cases  of  syphilis,  hsematocele  from  bruises,  and  may 
be  diagnosed  by  the  principles  laid  down  on  page  92.  Prognosis, 
so  far  as  fatal  results  are  concerned,  are  favorable,  but  unfavorable 
as  to  a  radical  cure,  and  palliative  treatment  is  difficult  to  apply. 
The  best  is  Hirsch's  Elastic  Truss,  Fig.  11,  page  29,  or  a  pessary 
of  sponge.  I  saw  a  very  bad  case  in  which  it  came  out,  and  could 
not  be  retained  by  anything  but  a  sponge  pessary.  I  took  a  sponge 
of  the  proper  size  and  covered  it  with  two  layers  of  oil  silk,  and 
inserted  it  in  the  vagina,  which  kept  it  in  place  while  the  patient 
was  quiet,  but  it  would  return  when  anything  heavy  was  lifted. 

The  coverings  are  skin,  superficial  fascia,  deep  fascia  and  peri- 
toneum. 

In  strangulation,  the  stricture  is  usually  at  the  internal  orifice,  in 
the  peritoneal  fold,  between  the  bladder  and  uterus.  When  it  is 
strangulated,  and  an  operation  becomes  necessary,  the  stricture 
should  be  divided  inward,  to  avoid  the  artery. 

Vaginal  Hernia. — The  tumor  may  form  in  the  anterior  or  pos- 
terior side  of  the  vagina,  and  fill  the  vagina,  and  press  on  the  one 
side  of  the  bladder,  producing  constant  micturition,  or  the  rectum, 


INFEEIOR   HERNIA   OF   THE   PELVIC   REGION.  113 

producing  tenesmus.  It  may  press  so  strongly  against  the  urethra 
as  to  produce  retention  of  urine.  It  generally  fills  the  vagina,  is 
soft,  and  easily  pushed  back,  if  the  patient  be  on  her  back  and  the 
hips  well  raised.  The  causes  are  the  same  as  in  other  pelvic  hernias. 
Diagnosis  is  simple,  and  the  case  easily  made  out  by  vaginal  ex- 
amination, assisted  with  catheter  and  finger  in  rectum.  Prognosis 
unfavorable  as  to  a  radical  cure,  it  being  next  to  impossible  to 
reach  it;  if  it  could  be  reached,  the  direct  method  by  incision  might 
be  performed,  and  the  wound  closed  with  Sim's  suture,  which  I 
would  certainly  recommend,  when  it  can  be  done.  The  palliative 
treatment  is  an  abdominal  supporter  and  a  Hirsch's  vaginal  truss. 
(Fig.  11,  page  29),  or  that  shown  by  Fig.  fig.37. 

37.    The  catheter  must  be  used  where  the 
urine  cannot  be  voided. 

Ischiatic  Hernia  forms  a  tumor  in  the 
region  of  the  ischiatic  notch,  and  under 
the  gluteus  maximus  muscle.  It  passes 
through  the  sciatic  notch  (Plate  ii,  e  f, 
page  15),  above  or  below  the  pyriformis 
muscle,  usually  below,  between  it  and  the 

f,  ,1       •     1  •  1    •  ■        1  Vaginal  Truss. 

spme  01  the  ischium,  lying  m  close  con- 
nection with  the  sciatic  nerve  and  the  internal  iliac  vessels.     The 
tumor  extends  outward,  and  opens  subintegumental  below  the  bor- 
der of  the  gluteus  maximus  muscle. 

Symptoms. — The  tumor  is  of  variable  size,  causes  more  or  less 
pain  from  its  pressure  on  the  nerves,  and  may  produce  cramps  in 
the  muscles,  and  neuralgia  from  pressure  on  the  sciatic  nerve.  It 
is  reducible,  and  this  assists  in  diagnosing  it  from  other  tumors  in 
this  region.  The  prognosis  is  favorable  in  its  reducible  condition, 
and  it  may  be  kept  up  with  an  elastic  bandage  and  compress,  as 
shown  in  Fig.  13,  page  29.  The  compress  is  placed  under  the 
elastic  bandage,  and  sewed  to  it  to  prevent  its  slipping  away. 

The  operation  for  strangulation  is  difficult,  as  the  incision  has  to 
be  large,  and  the  gluteus  muscle  dissected  up  and  turned  inward, 
and  the  parts  carefully  cut  on  a  director,  feeling  for  the  pyriformis 
muscle,  which  must  sometimes  be  divided.  The  neck  of  the 
sac  being  exposed,  the  stricture  should  always  be  cut  toward  the 
anterior  median  line,  to  avoid  the  nerves  and  arteries.  It  must  be 
carefully  examined,  and  if  sound,  returned,  and  the  internal  orifice 
closed  with  a  silver  ligature  cut  off  close,  or  ligatures  may  be 


114:  HERNIA. 

brouglit  out  in  tlie  lower  line  of  the  incision.  The  external  wound 
may  be  then  closed  with  silk  or  silver  ligatures.  The  wires  should 
be  untwisted  and  taken  out  on  the  eighth  day,  or  they  may  be  left 
in  and  cut  off  close  after  the  external  wound  has  closed. 

HERNIAS    OF   THE    MESOGASTRIC    REGION. 

See  Figure  30,  page  85.  These  are:  1.  Umbilical.  2.  Ventral. 
3.  Lumbral. 

Umbilical  hernia  is  known  by  its  position  at  the  umbilicus  (see 
Plate  1,  D.,  page  13).  It  is  often  congenital  in  bottumale  and  female 
children.  In  adult  life  it  is  much  more  common  in  females  than  in 
males,  especially  in  child-bearing  women,  and  those  who  are  laboring 
under  ovarian  tumors.  Ascites  in  the  male  and  female  is  often  a 
predisposing  cause  of  great  effect.  It  is  of  various  sizes,  from 
a  filbert  to  a  ten-inch  sac,  (see  Fig  5,  page  19),  and  it  often  reaches 
half  way  to  the  knees,  carrying  with  it  nearly  all  the  contents  of 
the  abdomen,  stomach,  spleen,  and  even  the  kidneys  in  some  cases. 
"When  small,  the  contents  are  most  invariably  omentum  or  omentum 
enclosing  the  intestine.  It  continues  to  increase  with  exercise  and 
from  its  own  weight,  and  every  pregnancy  enlarges  it. 

Causes. — Congenital  deficiency  is  the  principal  cause;  not 
tying  the  cord  close  enough  at  birth;  not  putting  on  or  keeping 
on  a  proper  bandage  after  the  removal  of  the  cord ;  and  afterward 
by  crying,  coughing,  sneezing,  laughing,  and  stooling,  one  of  the 
principal  causes  in  children ;  and  when  once  formed,  these  all  tend 
to  increase  it.  It  is  often  complicated  with  ventral  hernia.  I  saw 
a  large  umbilical  hernia  in  a  female  with  six  ventral  hernias, 
having  been  called,  with  several  other  physicians,  to  examine  the 
patient,  who  was  a  negro  slave,  and  had  been  sold  as  sound,  but 
upon  examination  was  thus  seen  to  be  afi'ected.  This  was  the 
most  remarkable  case  I  ever  saw  of  umbilical  hernia.  The  umbili- 
cal alone  was  as  large  as  a  child's  head.  The  woman,  who  was 
pregnant  at  the  time,  had  the  abdominal  muscles  completely  riddled 
with  ventral  hernias.  They  seemed  to  protrude  everywhere.  She 
stated  her  umbilical  hernia  was  congenital,  but  not  bad  until  she 
began  to  bear  children,  when  it  began  to  increase,  and  others  to 
form.  She  wore  a  duck  abdominal  supporter  made  by  herself, 
which  seemed  to  answer  every  purpose.  Her  general  health  did 
not  seem  to  be  affected  by  it,  and  she  had  done  ordinary  field  work 
as  any  other  hand.     The  diagnosis  is  early  made  out  and  the 


HERNIAS   OF  THE   MESOGASTRIC   REGION. 
Fig.  38. 


115 


Supporter  for  Umbilical  Hernia,  A,  B,  C. 


116 


HERNIA. 


tumor  can  always  be  seen,  and,  most  usually,  readily  reduced.  It 
is  said  to  become,  often,  irreducible,  but  this  I  cannot  believe,  as  I 
bave  never  seen  a  case  in  either  hospital  or  private  practice,  and  I 
am  now  old  enough  to  be  authority  on  such  a  subject.  Twenty- 
five  years'  close  practice  in  the  rural  districts  would  certainly  have 
given  me  one,  had  it  not  been  very  unusual;  though  nearly  all 
writers  on  hernia  have  reported  cases,  and  they,  therefore,  do 
unquestionably  occur. 

Prognosis  is  always  favorable,  as  it  can  be  reduced,  and  kept  re- 
duced, if  small,  by  a  spring  truss,  with  a  broad  concave  pad,  (see 
Fig.  18,  page  31),  and  a  convex  point  in  the  centre,  or,  which  is 
perhaps  better,  Hirsch's  elastic  umbilical  truss,  shown  in  Fig.  12, 
page  29. 

The  characters  of  this  hernia  are  various ;  sometimes  it  comes 
out  in  the  old  umbilical  cord,  separating  it,  and  pushing  the  peri- 
toneum before  it.  Again,  it  will  come  out  at  the  side  of  the  um- 
bilicus in  a  sort  of  slit,  and  press  open  the  fibres  of  the  transver- 
salis  muscle,  and  separate  the  two  recti  to  a  great  distance.  The 
epiploon  (omentum)  completely  covers  this  space,  and  is  most  usually 
pushed  through  the  opening.  It  could  hardly  be  otherwise,  but  by 
distention  this  is  often  ruptured,  and  the  intestine  comes  immedi- 
ately up  to  the  abdominal  peritoneum,  and  pushes  it  before  it,  with 
the  deep  and  superficial  fascia  (here  almost  together  and  combined 
into  one)  and  the  skin.  Consequently,  the  coverings  are  only  four, 
and  usually  only  three  can  be  seen  in  an  operation.  The  tumor  is 
transparent  in  recent  cases,  but  becomes  more  opaque  as  pressure 
ceases,  and  lymph  is  thrown  out. 

The  treatment  is  palliative 
or  curative.  The  palliative 
has  been  indicated,  to  a  cer- 
tain extent,  in  the  symptoms 
and  diagnosis.  Perhaps  the 
best  palliative  treatment  for 
an  umbilical  or  ventral  her- 
nia is  the  abdominal  bandage, 
shown  in  Fig.  12,  page  29,  or 
in  Fig.  38,  ABC,  page  115, 
and  Fig.  39.  This  gives  a  firm  support  to  the  entire  abdomen,  and 
by  adhesive  straps,  and  a  small  compress  over  the  umbilicus  before 
this  is  applied,  is  both  palliative  and  curative.  The  patient  can 
alwavs  be  made  comfortable  and  useful  with  this  apparatus. 


Fig.  39. 


Abdominal  Supporter, 


HERNIAS   OP   THE   MESOGASTEIC   REGION.  '  117 

The  radical  cure  is  easy  bythe  author's  process,  and  is  easy  of 
application.  I  have,  as  before  shown,  cured  the  only  two  cases 
treated;  see  report  of  child,  page  55.  I  give  below  the  history, 
taken  from  the  Galveston  Medical  Journal,  of  the  first  case  ope- 
rated on  with  the  present  needle,  and  the  manner  in  which  I 
now  perform  the  operation.  Keport  made  by  Dr.  C.  H.  Wilk- 
erson : — 

"  Elizabeth  Russell,  Irish,  aged  thirty-five,  applied  for  treatment  in 
St.  Mary's  Hospital,  Galveston,  Texas,  August  20th,  1869,  for  an 
umbilical  hernia  that  had  lasted  for  ten  years  ;  caused  by  lifting ; 
appeared  suddenly,  and  caused  great  pain  at  the  time ;  it  has  now 
increased  and  enlarged  to  about  the  size  of  an  orange  ;  is  now  (Au- 
gust 20th)  about  the  size  of  a  walnut,  and  evidently  contains  omen- 
tum. Collodion,  tannin,  bandages  and  trusses  had  all  been  tried, 
but  all  failed  to  do  any  good,  and  she  therefore  consented  to  an 
operation  for  a  radical  cure.  Operation  performed  by  Prof.  Greens- 
ville Dowell ;  needle  threaded  with  silver  wire  without  lines."  See 
page  60  for  full  account  of  case. 

The  irreducible  umbilical  hernia  should  be  kept  up  with  an  elas- 
tic bag-truss  or  bandage,  made  to  press  down  but  not  around  the 
neck  of  the  tumor,  which  may  be  of  various  shapes,  as  conical, 
sessile,  pedunculated,  etc.  These  conditions  should  always  be 
taken  into  consideration  in  preparing  a  support  of  any  kind. 

When  strangulated,  the  operation  may  be  performed  in  any 
one  of  the  three  methods;  by  cutting  from  within  to  without,  by  a 
fold,  direct  through  the  skin  to  the  superficial  fascia,  when  the  other 
coverings  must  be  very  carefully  raised  and  cut,  as  fully  described 
before,  using,  always,  the  grooved  director.  The  sac  being  reached, 
and  no  adverse  condition  being  indicated,  and  the  strangulation 
being  recent,  hernia  large,  no  stercoraceous  vomitings  or  hiccough, 
the  stricture  may  be  cut  outside  of  the  sac,  and  directly  upward, 
on  the  flat  director,  or  guided  by  the  finger. 

The  external  incision  may  be  made  on  the  side  of  the  tumor  or 
above  it,  in  a  transverse  line ;  it  may  be  made  small,  only  about  an 
inch,  and  Gay's  operation  performed  by  cutting  the  stricture  sub- 
cutaneously,  and  the  sac  and  contents  returned.  These  plans  must 
be  selected  according  to  the  judgment  of  the  operator,  and  strictly 
in  accordance  with  the  principle  laid  down.  The  hernia  being 
reduced,  the  surgeon  should  close  the  wound  with  deep  silver- wire 
sutures,  put  in  so  that  no  possible  enlargement  of  the  tumor  can 


118  HEENIA. 

return.     This  will  most  always  effect  a  radical  cure ;  and  Wood's 
pins  are  also  quite  efficient  and  useful  in  this  hernia. 

Ventral  Hernia. — It  may  form  in  any  portion  of  the  abdominal 
wall,  and  the  varieties  denominated  lumbral,  epigastric,  hypochon- 
dric,  are  all  of  the  same  nature,  and  are,  really  speaking,  ventral 
hernias  of  different  locations,  which  are  important,  as  the  coverings 
are  different,  or  rather  the  connections  are  different  in  the  different 
positions.  Hence  we  now  limit  ventral  hernia  to  the  median  line 
and  all  between  it  and  the  semicircular  line,  above  and  below  the 
umbilicus. 

The  symptoms  are  the  same  as  those  of  umbilical  hernia.  The 
tumor  is  not  nearly  so  large  as  umbilical,  and  it  is  rarely  congeni- 
tal, usually  traumatic,  from  a  punch,  hook,  or  incised  wound,  and 
burns.  I  saw,  as  before  stated,  when  speaking  of  tobacco  injections 
and  their  danger,  the  negro  woman,  Briggs,  who  had  a  large  burn 
just  to  the  left  side,  and  about  two  and  a  half  inches  above  the 
ilio-pubic  ligament.  The  hernia  was  large,  about  the  size  of  a 
small  pig,  and  looked,  before  the  post-mortem,  like  a  pig  in  the 
skin,  and  between  the  skin  and  abdominal  wall.  Strangulation 
had  taken  place  by  impaction  the  day  before,  and  it  became  very 
painful.  Two  physicians  were  called,  and  they  failed  to  reduce  it. 
They  gave  her  a  tobacco  injection  and  sent  for  me ;  before  I  arrived 
the  patient  was  dead;  the  body  was  not  cold.  It  was  desired 
I  should  make  a  post-mortem,  which  I  did,  after  sending  for  my 
instruments.  I  did  not  find  any  adhesion  nor  any  serious  inflamma- 
tion. The  contents  were  much  congested,  but  in  a  condition  to 
have  been  returned.  I  reduced  the  tumor  without  cutting  the  stric- 
ture, which  evidently  showed,  to  my  mind,  the  cause  of  death  was 
tobacco  injection.  I  therefore  recommend  them  never  to  be  used. 
The  only  thing  that  is  admissible  is  tobacco  steeped  in  ice  water 
and  applied  externally.  This  will  be  quite  active  enough,  and  will 
produce  nausea  and  vomitings  in  the  patient.  This  patient  might 
have  been  relieved  by  the  hydraulic  syringe,  as  the  sigmoid  flexure 
of  the  colon  was  in  the  sac,  with  nearly  all  the  ilium.  The  opening 
was  of  a  very  irregular  shape,  and  in  two  departments,  connected 
by  an  open  space,  in  which  hung  the  mesentery. 

The  incision  for  strangulation  may  most  usually  be  made  after 
Gay's  method,  and  the  stricture  cut  subcutaneously.  The  incision 
is  best  made  inside  of  the  median  line,  or  transversely,  according 
to  the  course  of  the  muscles. 


HERNIAS   OF   THE   EPIGASTEIC   REGION.  119 

Lumhral  hernia  occurs  in  the  lumbral  space,  between  the  orest 
of  the  ihum,  and  up  to  the  small  ribs.  It  comes  out  at  the  inner 
line  of  the  quadratus  lumborum  muscle,  or  through  its  body. 

It  is  usually  produced  by  wounds,  either  gunshot  or  incised, 
sometimes  by  deep-seated  abscesses. 

The  symptoms  are  the  same  as  in  ventral,  and  it  requires  the  same 
treatment.  The  contents  are  usually  the  colon,  and  when  it  cannot 
be  returned,  the  artificial  anus  ought  to  be  made  on  the  non-peri- 
toneal or  posterior  and  outer  side  of  the  colon;  hence,  in  operating 
for  strangulation,  the  incision  should  be  made  with  reference  to  this 
anatomical  condition. 

HERNIAS   OF   THE   EPIGASTRIC   REGION. 

See  Plate  i,  A.  These  are  external  and  internal.  The  external 
are  epigastric,  right  and  left  hypochondric;  internal  diaphragmatic, 
right  and  left. 

Epigastric  hernia  is  easily  known.  A  small  tumor  forms  just 
under  the  ensiform  cartilage,  or  a  little  to  the  right  or  left  of 
it.  It  is  reducible,  and  has  but  four  coverings:  skin,  superficial 
fascia  and  deep  fascia,  often  congenital  from  malformation,  as 
hare-lip,  and  spina  bifida.  When  reduced  it  easily  returns,  and 
leaves  a  well-defined  hole. 

Causes. — These  are  sometimes  congenital,  and  are  very  rare  in 
those  who  are  well  formed,  except  it  be  produced  by  a  kick,  push 
of  plow-handle,  rake  or  hoe,  a  hook  of  cattle,  or  wounds  in  this 
region. 

Treatment. — It  can  be  easily  retained  with  an  umbilical  truss 
or  an  elastic  bandage.  It  does  not  produce  inconvenience,  and  is 
not  very  liable  to  strangulation  unless  large.  The  contents  are 
usually  portions  of  the  omentum,  stomach,  small  intestines,  and 
the  mesentery;  hence,  patients  suffering  from  it  are  liable  to  indi- 
gestion, cardialgia,  and  flatulency.  In  operating  for  strangulation, 
the  stricture  should  be  cut  upward,  to  avoid  the  epigastric  arteries. 

Radical  Treatment. — It  can  be  cured,  either  with  Wood's  pins  or 
the  author's  process.  It  is  well  adapted  to  the  author's  process, 
and  it  is  readily  and  easily  done,  the  ligatures  put  in  line  over 
the  opening,  and  tied  above  a  piece  of  cork  or  soft  wood,  covered 
with  adhesive  plaster. 

Case  16.  Mr.  Huffman,  Lebanon,  Collin  Co.,  Texas,  1S72. 
Epigastric  hernia.     Opening  very  small ;  had  been  twice  strangu- 


120  HERNIA. 

lated.  Operation  by  "  subcutaneous  suture  "  (see  Plate  iv,  Fig.  2, 
page  49),  Dr.  Shelburn  giving  chloroform.  The  opening  was  so 
small  that  the  end  of  the  little  finger  could  not  be  inserted  to  guide 
the  needle ;  but  two  sutures  were  put  in  and  tied  over  a  piece  of 
soft  wood,  covered  with  cloth.  The  stitches  were  kept  in  eight 
days.  Patient  remained  cured  for  one  year,  but  it  returned  after  a 
spell  of  vomiting  from  dissipation,  Mr.  H.  says  it  has  done  him  a 
great  deal  of  good,  as  he  can  keep  it  up  with  an  umbilical  truss, 
which  he  could  not  do  before.     Intends  to  be  operated  on  again. 

Sypochondric  Hernia  is  the  same  as  lumbral,  only  the  quad- 
ratus  lumbarum  muscle  is  not  involved.  Its  coverings  are  skin, 
superficial  fascia,  external  oblique,  internal  oblique,  and  transverse 
muscles,  deep  fascia  and  peritoneum.  The  stricture  is  usually  at 
the  mouth  of  the  sac,  and  where  the  transverse  muscle  covers  it. 
The  incision  may  be  made  to  the  side,  above  or  over  the  tumor, 
generally  along  the  neck,  transverse  is  the  best,  and  the  stricture 
cut  upward.  The  opening  of  the  sac  is  governed  by  the  rules  so 
often  mentioned  before,  and  not  necessary  to  repeat  here.  The 
prognosis  is  favorable. 

Diaphragmatic  Hernia. — There  are  several  varieties  of  this ; 
first,  where  the  tumor  passes  through  the  oesophageal  opening,  as 
seen  in  Plate  iii,  c  d,  page  17.  Where  it  passes  through  the  opening 
for  the  ascending  vena  cava.  It  occurs  also  congenital  (see  Sir 
Astley  Cooper's  work,  by  Hey),  but  is  most  usually  produced  by . 
wounds,  gunshot  or  incised.  The  contents  are  usually  the  stomach 
and  omentum,  but  large  portions  of  the  jejunum  have  also  been 
found  in  some  cases.  It  presses  on  the  lungs,  causing  cough  ;  and 
it  passes  through  the  diaphragm,  and  causes  constant  hiccough.  In 
traumatic  cases,  blood  is  usually  expectorated  in  the  first  stages. 

Symptoms  are  usually  obscure  and  hard  to  define.  There  ia 
more  or  less  pain  at  the  neck  of  the  sac,  but  its  radiation  is  so 
great  it  is  hard  to  localize  it.  Usually  there  is  constipation,  with 
vomitings  of  bile,  mucus,  and  streaks  of  blood.  When  it  is  from 
a  wound,  it  will  generally  assist  us  in  the  diagnosis,  and  its  position 
can  be  defined.  When  the  lungs  are  involved,  we  can  tell  which 
side  the  hernia  is,  and  usually  its  size,  by  percussion  and  ausculta- 
tion. There  is  a  depressed  feeling  from  the  first ;  anxious  counten- 
ance— indicating  general  distress.  Pulse  weak  and  wiry;  some 
fever ;  much  thirst,  with  a  dry  tongue ;  hiccough  depressing ;  patient 
finally  wanders  and  dies  comatose. 


■    HEENIAS   OF   THE    EPIGASTRIC   REGION.  121 

Causes. — We  have  already  given  these ;  malformation  was  the 
cause  in  a  child,  given  by  Gross  ;  a  gunshot  wound,  in  a  case  of  Sir 
Benjamin  Brodie  and  Mr.  Guthrie ;  a  traumatic  wound,  involving 
the  ribs,  in  one  of  Sir  Astley  Cooper's  cases;  obesity,  with 
vomitings,  in  the  case  of  Senator  Barrow,  of  Louisiana.  He 
had  the  best  of  surgeons  from  Philadelphia,  and  those  of 
Washington,  but  his  case  was  not  diagnosed  until  a  post-mortem 
was  made.  The  hernia  was  small,  and  seemed  to  have  been  purely 
idiopathic,  passing  through  the  vena  cava  orifice.  The  prognosis 
is  exceedingly  grave — no  opportunity  of  replacement ;  no  means  of 
retention  after  reduction,  if  it  were  possible.  Consequently,  the 
treatment  resolves  itself  into  constitutional,  as  venesection ;  opium, 
in  intervals  of  vomitings;  injections,  rest,  quiet;  position  upright, 
with  chest  flexed  on  the  abdomen,  to  relax  the  diaphragm ;  knees 
on  pelvis,  and  pulling  the  bowels  downward ;  chloroform,  warm 
baths  and  injections,  with  continual  syringing  with  warm  water ; 
milk  diet,  with  a  little  lime  water.  This  is  about  all  that  can  be 
done  for  the  patient.  Mr.  Guthrie  has  advised  gastrotomy  for 
strangulation,  and  I  think  this  ought  to  be  practiced  when  the  case 
can  weU.  be  made  out,  and  the  rupture  sewed  up  with  silver  wire, 
and  cut  off  close.  This  would,  no  doubt,  save  life  in  many  cases, 
if  done  early  enough,  and  it  is  certainly  justifiable,  as  otherwise 
death  is  inevitable. 

Intestinal  Hernia. — There  is  an  encysted  form  of  entero-intesti- 
nal  hernia,  which  is  produced  in  one  of  three  ways. 

1.  Plate  III,  G,  page  17  shows  the  first  variety,  where  a  portion  of 
the  intestine  has  passed  through  the  mesocolon,  and  become  strangu- 
lated at  the  point  where  it  passes  through  the  omentum,  or  a  loop 
of  intestine  adhered  together. 

2.  Where  the  omentum  envelops  the  intestine  and  strangulates 
it,  by  constriction  of  its  orifice,  and  by  impaction  of  the  bowel. 

3.  Hernia  by  diverticulum,  as  seen  in  Plate  iii,  E,  page  17.  In 
this  variety  the  muscular  coats  of  the  intestine  itself  give  way, 
and  the  fecal  contents  are  pushed  through  its  coverings — the 
mucous  and  the  serous  coats — like  the  formation  of  an  aneurism. 
They  are  all  known  by  their  general  symptoms,  as  there  are  no  ex- 
ternal tumors,  and  rarely  can  any  be  felt  internally.  Peritonitis  is 
developed  early,  and  all  the  symptoms  attending  its  local  effects 
are  produced.  Pain  in  the  region  of  the  umbilicus ;  constipation 
complete  in  the  two  first  varieties,  but  not  in  the  diverticulum 

9 


122  HERNIA. 

variety;  vomitings,  first  of  contents  of  stomach — mucus,  bile — and 

lastly,  intestinal  contents ;  hiccough,  general  collapse,  and  death. 

The  treatment  is  based  on  the  general  plan  of  diaphragmatic 

hernia;  low  diet,  opium,  chloroform,  injections,  mercurials,  in  small 

doses,  warm  baths,  venesection,  and  ice  wrapped  in  flannel   over 

the  seat  of  pain.     When  flatulence  is  very  great  the  intestine  is 

punctured  with  a  small  trocar,  and  the  gas  let  ofi'.     Position — 

turning  on  right  and  left  side,  and  kneading  the  bowels  ;  elevating 

the  head  and  body ;  elevating  feet  and  body.     These  all  failing  we 

should  resort  to  gastrotomy  in  the  median  line,  and  relieve  the 

stricture  in  the  usual  way.     If  the  sac  has  bursted  and  contents 

let  out,  they  should  be  washed  out  with  warm  water,  perfectly 

clean.     The  dead  portions  all  cut  off,  and  the  intestines  united  with 

silk  thread  by  the  running  suture  on  the  mucous  surface,  as  far  as 

possible ;  then  the  s;ut  should  be  turned 
Fig.  40.  Fig.  41.  f  '  ° 

in,  and  the  union  completed  by  the 
intestinal  suture  usually  used  for  in- 
cised wounds,  invented  by  Lambert 
and  Gely ;  Lambert's,  Fig.  40 ;  Gely 's, 
Fig.  4L 

The  external  wound  is  then  closed, 
as  in  cases  of  the  Csesarean  section. 
This  will  save  some  cases  that  would 

Lambert's  Suture.    Gely's  Suture.      .  •,    ^^       t  i      ^        ^  t      ^  ^ 

mevitably  die,  and  should  always  be 
resorted  to  when  all  others  fail. 

Invaginatic  hernia  (intussusception),  see  plate  iii,  P,  page 
17.  This  is  a  common  affection,  and  one  of  the  most  serious 
lesions  that  can  occur.  The  symptoms  are  the  same  as  the  last 
described ;  no  tumor,  only  general  symptoms  to  guide  us,  as  con- 
stipation, vomitings  (stercoraceous),  hiccough,  weak,  wiry  pulse, 
and  all  the  symptoms  of  local  peritonitis,  at  first,  and  general  peri- 
tonitis following;  anxiousness  of  countenance,  constant  desire  to 
stool,  which  is  almost  pathognomonic  of  strangulated  intestinal  ob- 
struction. Treatment  is  precisely  the  same  as  the  above  variety 
of  hernia,  but  more  is  to  be  hoped  for  from  general  treatment,  and 
the  vis  reductio  naturae,  than  in  intestinal  hernia.  So  much  so, 
that  some  surgeons  recommend  that  no  external  incision  should  be 
made,  which  I  think  is  bad  advice.  When  the  patient  is  evidently 
verging  on  collapse,  or  about  to  sink  from  exhaustion,  he  should  be 
put  under  chloroform,  and  gastrotomy  performed — invaginated  por- 


REMOVAL   OF   THE   SEPTUM   IN  ARTIFICIAL  ANUS.  123 

tion  seized  and  cut  off,  union  of  intestines  effected  as  before,  by 
running  sutures,  and  intestinal  suture  of  Lambert  or  Gely,  and 
tbe  parts  brought  up  to  the  external  wound,  where  it  may  adhere. 
Two,  and  even  six  feet  of  intestines  have  thus  been  removed,  and 
the  patient  has  recovered.  It  is  death  without  this  in  most  cases, 
as  the  following  statistics  show  : — 

Dr.  William  Brinton,  from  1200  post-mortems,  gives  the  following 
results  :  Intestinal  causes  produced  (besides  hernia)  280  cases ; 
about  43  per  cent,  was  due  to  intestinal  intussusception.  The 
locality  of  the  intussusception  was,  at  the  junction  of  ilium  and 
ccecum,  56  per  cent.;  ilium  alone,  28  per  cent.;  jejunum,  4  per  cent.: 
colon,  12  per  cent.  65  per  cent,  of  the  whole  number  of  intestinal 
obstructions  were  from  internal  strangulation  (by  bands,  etc.).  The 
smaU  intestines  were  affected  in  95  per  cent,  of  all  cases ;  strictures 
and  twistings  involving  the  large  intestines,  88  per  cent,  of  all  cases. 
Men  and  women  are  equally  liable,  but  obstructions  from  impacted 
gall  stones  are  four  times  more  frequent  in  men  than  in  women. 

A  New  Instrument  for  the  Removal  of  the  Septum  in  Artificial  Anus. 

In  1858  I  had  under  treatment  Orlando  Orr,  who  had  been 
shot  several  years  before,  and  while  treating  him  I  devised  the 
above  instrument,  but  did  not  find  it  necessary  to  make  use  of  it, 
as  will  be  seen  by  the  report  of  his  case  below,  but  I  have  always 
thought  this  would  be  a  better  instrument  than  any  then  or  now 
in  use.     It  will  be  understood  from 

Fig.  42. 

the  cut,  Fig.  42.  The  female  blade 
is  made  to  receive  the  male  blade, 
after  the   principle   of  waffle   irons, 

and  they  are  shaped  to  resemble  the  ilio-csecal  valve,  and  to  cut 
just  such  a  septum.  It  is  made  to  pass  up  with  one  blade  in 
each  fold  of  intestine,  and  then  tightened  with  the  screw.  It 
does  not  cut  the  septum  in  two,  in  front,  which  I  think  is  import- 
ant in  assisting  to  effect  a  cure  after  the  connection  between  the 
folds  of  the  intestines  is  complete.  I  found,  also,  in  treating  Mr. 
Orr,  that  the  greatest  trouble  in  getting  union  in  the  flaps  was  the 
pressure  of  gas  against  them,  hence,  in  all  these  cases  the  flaps 
must  be  cut  so  as  to  make  valves  that  will  press  one  against  the 
other;  or  there  must  be  put  in  a  silver  tube,  as  in  tracheotomy,  to 
prevent  the  gas  from  forming,  and  this  must  be  so  small  that  it  can 
be  easily  closed  after  union  has  been  secured    or,  as  I  believe,  it  will 


124  HERNIA. 

soon  close  of  itself,  if  the  tube  be  not  too  large.  This  instrument 
is  light ;  has  no  long  handle  like  Dupuy tren's ;  no  derrick  like  Dr. 
Prince's,  and  it  makes  pressure  in  the  centre  with  merely  coapta- 
tion at  the  edges,  with  three  points  to  cut  through  and  hold  the 
instrument  in  place.  It  should  be  kept  in  until  the  inner  septum 
is  cut  through,  which  will  leave  an  opening  very  much  like  the 
ilio-csecal  valve;  after  this  heals,  the  external  wound  may  be 
closed.  I  have  not  had  any  case  to  treat  since  Mr.  Orr's,  or  I 
should  have  tried  this  instrument. 


The  following  report  of  a  case  operated  on  by  me  at  the  Univer- 
sity Hospital,  Philadelphia,  September  13,  1876,  was  received  too 
late  for  insertion  in  its  proper  place  : — 

September  13th,  1876.  Mr.  W.,  who  is  afflicted  with  oblique  in- 
guinal hernia,  came  to  hospital  to  be  radically  cured.  His  case  was 
given  to  Prof.  Dowell,  who  operated  by  his  own  new  method,  to-day. 
On  recovering  from  ether  he  complained  of  considerable  pain,  for  the 
relief  of  which  one-fourth  grain  morph.  sulph.  was  given  by  hypo- 
dermic injection.     Evening,  temperature,  101°;  pulse  74. 

September  24th.  Morning,  temperature  100° ;  pulse  60.  Suffer- 
ing frequent  pain,  running  from  back  to  groin ;  found  it  necessary 
to  give  another  hypodermic  injection  of  one-fourth  grain  morphia. 
Evening,  temperature  1011° ;  pulse  78.  Belly  slightly  tympanitic. 
Repeated  morphia  injection  in  evening. 

September  15th.  Administered  a  soap  and  water  injection,  with 
the  effect  to  remove  tympanitic  condition  of  abdomen,  and  relieve 
pain.  No  abdominal  tenderness  on  pressure,  except  within  a  small 
space,  including  the  seat  of  operation.  Morning,  temperature 
991°;  pulse  74.     Evening,  temperature  1001°;  pulse  84. 

September  20th.  Bowels  have  been  kept  open  by  enemata; 
appetite  and  general  health  very  good;  have  been  keeping  on  low 
diet ;  removed  the  wire  sutures  to-day ;  very  little  suppuration ;  a 
good  deal  of  lymph  effused  in  sac;  no  pain.  Pulse  and  tempera- 
ture normal. 

September  23d.  Hardened  lymph  in  sac  being  rapidly  absorbed. 
No  pain  complained  of.     Bowels  moved  naturally. 

September  25th.     Feeling  quite  well ;  wished  to  get  out  of  bed. 

September  27th.     Got  up  this  morning  and  took  a  short  walk. 

September  30th.     Doing  hght  work  in  the  ward. 


TABLE   OF   OPERATIONS. 


125 


05 

1-1          ►-!  1-1  >->                 1-1                 h-i 

CT          *-  OS  t-O                 l-i                ©          CO 

10^               C&Ol*i-WtO               >-^ 

p 
a 

Sept.  11, 1859. 

Sept.  1,  1862. 

Sept.  25,  1862. 

Oct.  24,  1862. 

May  10,  1867. 
1869 

Aug.  20, 1869. 

1870 

June,  1871. 
June,  1871. 

Feb.  18,  1872. 

April,  11, 1876. 
April,  19,  1876. 
April  20,  1876. 

May  26,  1876. 

Sept.,  1876. 

J.  H.  Mayfield     . 
French  Boy    .    . 

John  Foster    .     . 

Philip  Brown  .     . 
Henry  Smith  .     . 
Josey  Bell  .    .     . 

J.  J.  Posey      .     . 

Wilson   .... 

Abram  Thompson. 

Drayton .... 

Negro  child,  Mrs. 
Kyle's      .    .    . 

a                   It 

Overton  .... 
W.  R.  Johnson    . 

Mrs.  Russell    .     . 

1 

CD 
O 

P 

S" 
p 

fcO        bO       ^  Oi  Oi             *                -_        to 

O         GO        ^  CO  ^               _                   '*'         <W 

OS            to  to       '     ^            ■               *. 
en            to*.       _    "^           ^              to 

Black. 

English. 
Clerk. 

Irish. 
French. 

Texan. 
<< 

German. 

Black. 

Texan. 

Ameri- 
can. 
Swede. 

With  sur- 
geon's 
needle. 

With  3-in. 
needle. 

Oblique 
inguinal. 

Umbilical. 

Inguinal. 

Umbilical. 

Ing  u  i  n  0  - 

scrotal. 

Ing  u  i  n  0  - 

scro  t  a  1. 

It 

Hernia  tes- 
ticalis. 

Ing  u  i  n  0  - 
scrotal. 

c 

CD 

i. 

o 

3 

J-i          h-i 

m 
a 

CD 

d 

o 
c 

CD 

- 

1-1  H-i          1 

CD 

t-i                 H' 

E? 

:                        '  ■                                                          '•        '• 

l-*h-i                  H-iH-*;              t— 1                          h-Ah- lh-i(— *                  )— lh-ih-i|— 1*              » 

a 

CD 
p. 

-    1 

:       ^     \           '•   '•       '•   '•       H-i     1-1 

M. 

CD 
p. 

:         :'         :             :*:'::         • 

0 

CD 
p. 

E 

CD  ' 

> 

3 
< 

< 

^^ 
&2 

3  t 

fT 
o 
p 

31 
< 

CI. 

o 
-i 

0 

n 
o 

3. 

Dr.  Wilkerson ;  re- 
turned. 

Scrotum  suppurated; 

had  some  fever. 
No  bad  symptoms. 

2  operations ;  some 
fever;  both  failed. 

Now  Dr.  Mayfield,  of 
Hemstead,  Texas. 

Two     onerafions     bv 

First  case  treated  at 

Columbia,  Texas. 
Oyster  Creek,  Texas, 

One  stitch,thirty  days 
Sandy  Point,  Texas, 
two  sutures. 

Operation  a  success, 
cut  open,  reclosed, 
hunting  for  a  wire. 

p 

01 

ORIGINAL  CONTRIBUTIONS  TO  OPERATIVE 

SURGERY 


AND 


NEW    SURGICAL    INSTRUMENTS. 


Causes  of  Urinary  Calculi. 

The  primary  cause  of  urinary  calculi  is  some  form  of  dyspepsia, 
or  a  derangement  of  the  organs  of  assimilation,  injuries  to  the 
spine  frequently  producing  these  derangements  in  the  organs  of 
assimilation.  The  use  of  lime-stone  water,  as  indicated  in  this 
country  by  the  great  increase  of  cases  of  stone  in  Kentucky, 
Tennessee,  Illinois,  and  Indiana;  there  being  reported  in  these 
States,  in  the  year  1860,  respectively  (deaths  in  these  States  61,247), 
31,  30,  26,  25,  total  112;  while  in  the  whole  United  States, 
of  31,000,000  inhabitants,  there  were  reported  only  684  deaths. 
Of  these  607  were  males  and  67  females. 

We  give  a  table  of  the  deaths  in  all  the  States  from  stone 
during  the  year  ending  June  1st,  1868 :  — 


Males. 

Females. 

Total 

Maine,    .    .    .    . 

19 

4 

23 

New  Hampshire, 

13 

1 

14 

Vermont,     .     .     . 

14 

0 

14 

Massachusetts,  . 

30 

7 

37 

Rhode  Island, 





Connecticut, 

13 

1 

14 

New  York, 

82 

4 

86 

Michigan,      .     . 

13 

— 

13 

Wisconsin,  .     . 

11 

2 

13 

Minnesota,     .     , 

— 

1 

1 

Nebraska,   .     . 

— 



— 

New  Jersey, 

9 

1 

10 

Pennsylvania, 

60 

3 

63 

Ohio,    .... 

61 

3 

54 

Indiana,       .     . 

24 

2 

26 

Illinois,     .     .     . 

23 

2 

25 

Iowa,       .     .     . 

8 

— 

8 

Kansas,     .    .    . 

1 

1 

2 

Delaware,    .     . 

.      4 

1 

5 

Maryland,      .     . 

8 

2 

10 

Males.   Females.    Total, 


Dis.  of  Columbia, 
Virginia,  .     .     . 
North  Carolina, 
Kentucky,     . 
Missouri, 
South  Carolina 
Georgia, 
Florida,    . 
Alabama, 
Mississippi, 
Louisiana, 
Arkansas, 
Texas,     . 
Oregon, 
California, 
Dakota,     .     .     , 
Washington  Ter 
New  Mexico, 
Utah,      .    .    . 


According  to  the  above  statistics,  there  has  been  about  one  death 
in  every  five  thousand  of  the  inhabitants  throughout  the  entire 

127 


3 

3 

6 

34 

6 

40 

33 

1 

34 

24 

6 

30 

12 

— 

12 

16 

3 

19 

26 

3 

29 

3 

1 

4 

16 

5 

21 

13 

— 

13 

2 

1 

3 

5 

2 

7 

7 

1 

8 

1 

— 

1 

1 

— 

1 

128  OEIGINAL    CONTRIBUTIONS   TO    OPERATIVE   SURGERY. 

United  States ;   while  in  the  four  States  above  classed  there  was 
one  death  in  about  every  five  hundred  and  fifty. 

These  four  States  have  a  greater  proportion  of  lime-stone  water, 
and  the  people  use  well  water  instead  of  cistern,  while  in  Louisiana 
there  were  only  three  deaths  in  a  population  of  708,002 ;  and  while 
in  the  four  States  noted  there  were  112  deaths  out  of  a  population 
of  5,328,864;  therefore  I  assume  that  the  greatest  predisposing 
cause  is  the  use  ,of  lime-stone  water  (hard  water). 

Calculi  are  either  renal  or  cystic.  Kenal  calculi  are  those  cases 
where  the  stone  forms  in  the  pelvis  of  the  kidney  and  passes  down  to 
the  bladder,  producing  what  is  called  a  fit  of  gravel,  known  by  acute 
pain  in  the  region  of  the  kidney  and  along  the  line  of  the  ureter, 
producing  burning  urine  accompanied  with  a  partial  suppression, 
and  urine  filled  with  the  peculiar  sediment  that  the  stone  is  com- 
posed of.  Cystic  calculus  is  known  by  its  forming  in  the  bladder  by 
accretions  or  deposits  or  some  small  particles  of  stone  that  come 
down  into  the  bladder  from  the  pelvis,  or  that  form  on  some  foreign 
body  introduced  through  the  urethra,  such  as  pieces  of  bougies, 
pieces  of  bullets,  etc.  Cystic  calculi  are  known  by  continual  irrita- 
tion of  the  bladder,  by  a  profuse  discharge  of  mucus,  pus  and 
bloody  urine,  a  sudden  stopping  in  the  discharge,  and  pain  in  the 
glans  penis.  Cystic  calculi  may  be  encysted  or  enclosed  in  a  sac, 
and  then  many  of  the  above  symptoms  are  not  to  be  found,  but 
pressure  in  the  rectal  region.  The  stone  can  usually  be  sounded, 
and  should  always  be  so  diagnosed  before  attempting  any  operative 
procedure;  which  brings  us  to  the  main  subject  of  this  paper, 
"The  Operative  Procedure  for  the  Belief  of  Stone." 

Recto-  Vesical  Section. — Amongst  the  first  operative  procedures 
was  that  of  securing  the  stone  with  the  fingers  in  the  rectum,  and. 
cutting  through  all  the  tissues  down  to  the  stone,  and  allowing  the 
wound  to  heal  up  by  granulation.  This  is  never  practiced  at  the 
present  day. 

Lateral  OperatiorL. — ^The  operation  of  cutting  to  either  the  left 
(which  is  preferred)  or  the  right.  This  is  now  a  popular  proce- 
dure, and  is,  all  things  considered,  perhaps  the  safest  and  the  best, 
for  the  following  reasons :  There  is  no  danger  of  producing  impo- 
tency  in  the  patient,  with  less  liability  to  urinary  infiltration ;  but 
is  limited  to  stones  of  the  size  called  large,  and  not  admitting  of 
the  passage  of  very  large  ones,  when  the  bilateral  should  be  pre- 
ferred. 


NEW  SURGICAL   INSTRUMENTS.  129 

Median  Section. — This  is  the  present  popular  mode  of  procedure, 
but,  like  the  lateral,  is  not  suited  to  large  stones,  but  has  the  ad- 
vantage of  avoiding  hemorrhage  by  cutting  in  the  median  line. 
By  combining  median  section  with  lithotriptsy,  this  can  be  used 
for  all  cases,  either  large  or  small  size  stone. 

Hyper-puhic  Section. — This  is  now  scarcely  justifiable,  and  is  only 
to  be  adopted  in  large  stones,  and  more  particularly  in  females. 
The  dangers  in  this  operation  are  peritoneal  inflammation,  urinary 
infiltration  and  pyaemia.  Since  the  improvements  in  the  operative 
procedure  for  vesico-vaginal  fistula,  the  hyper-pubic  operation  is  not 
justifiable,  there  being  no  danger  in  the  vagino-rectal  section,  which 
will  admit  of  the  extraction  of  the  largest  calculi,  and  the  wound 
in  the  vaginal  wall  can  be  closed  in  eight  days  with  entire  safety. 
This  should  be  done  in  all  females,  except  where  the  stone  is  small, 
and  cannot  be  crushed  by  lithotripts.  Where  the  stone  is  very 
small  in  females,  the  urethral  section  may  be  performed,  cutting  only 
through  the  anterior  sphincter,  and  dividing  the  sphincter  vesicae ; 
cut  in  a  given  direction  to  the  right  or  left  side,  and  dissect  up 
to  the  right  or  left  as  far  as  the  symphisis  pubis,  and  backward  for 
three  quarters  of  an  inch,  then  dilate  with  the  fingers,  passing 
the  forceps,  and  securing  the  stone  and  extracting  it.  If  it  is  too 
large  to  pass,  it  should  be  crushed  with  the  lithotript,  and  then 
extracted  by  particles  with  the  scoop. 

INSTRUMENTS   IN  USE   FOR   THE   LATERAL   AND   BILATERAL   OPERA- 
TION. 

Director  and  Bistoury. — The  director  in  common  use  has  a  deep 
groove  in  its  back,  and  a  probe-pointed  bistoury  is  used  to  make  the 
incision  through  the  membranous  portion  of  the  urethra  and  the 
prostate  gland.  Any  straight  knife  may  be  used,  but  the  best  of 
all,  in  my  opinion,  is  the  gorget  with  a  movable  blade,  to  enable  it 
to  be  well  guarded  and  kept  very  sharp.  The  reasons  I  prefer  this 
form  of  knife  are  these :  It  cuts  only  on  its  point,  has  no  sharp 
corners  or  convex  surface,  and  will  not  wound  the  rectum  if  held 
downward ;  the  rectum  cannot  be  pressed  against  its  edge  by  its 
own  action ;  while  the  bistoury  cuts  not  only  on  the  point  desired, 
but  is  made  to  cut  on  its  entire  edge,  and  is  liable  to  have  the 
rectum  pressed  up  against  it,  and  thereby  cut,  which  cannot  be 
done  with  the  gorget. 


130  OEIGINAL   CONTEIBUTIONS   TO   OPERATIVE   SURGERY. 

Dr.  Goodwin's  Staff  and  Blades. — A  description  of  Dr.  Good- 
win's instruments  was  given  in  the  March,  number  of  the  Galves- 
ton Medical  Journal,  1868,  page  136,  to  which  I  refer  the  reader. 
Dr.  Goodwin's  staff  is  fenestrated  where  the  common  staff  is 
grooved,  and  his  gorget  is  double,  as  will  be  seen,  and  makes  a 
bilateral  incision  with  the  centre  point  or  probe,  but  made  to  fit 
into  the  fenestra,  after  the  plan  of  the  bayonet  hitch.  The  point 
of  entrance  is  immediately  at  the  commencement  of  the  fenestra, 
and  once  inserted,  it  cannot  get  out.  This  is  of  the  utmost  im- 
portance, and  is  much  better  than  to  use  Prof.  Post's  instrument, 
for  with  the  instrument  of  Dr.  Post  the  staff  has  to  be  withdrawn, 
and  then  the  director  inserted  into  the  bladder,  which  is  quite 
unnecessary  with  Goodwin's  instruments.  Dr.  Post's  instrument 
'is  as  securely  fixed,  and  will  not  permit  the  cutting  instrument 
to  slip  out  as  does  Goodwin's,  and  is,  therefore,  preferable  to  the 
groove  director  of  Prof.  Smith ;  but  for  reasons  stated  above,  I 
prefer  Goodwin's  staff  to  all  others ;  but  it  should  be  made  more 
angular,  and  made  to  fit  up  under  the  pubis,  as  does  Prof.  Smith's. 
With  its  present  straight  curve,  the  rectum  will  be  much  more 
liable  to  be  cut,  and  this  should  be  changed.  I  would  have  Good- 
win's gorget  with  a  straight  handle  and  no  angles,  for  the  angles 
will  press  down  on  the  perineum  and  prevent  its  motion.  I  would 
have  the  blades  made  movable,  as  the  present  gorget,  so  that  one 
or  two  blades  could  be  used,  and  of  different  sizes,  as  the  blades 
of  the  gorget  are  made,  so  that  the  operator  could  select  his  own 
size  and  that  suitable  to  the  case  under  treatment. 

The  instruments  I  prefer,  and  the  best  of  all  instruments,  are 
these  : — Prof.  Smith's  curve  to  the  director  and  angular  incision ; 
Goodwin's  fenestrated  grooved  director ;  the  gorget  made  movable 
and  straight,  with  single  or  double  blades,  but  only  the  point  with 
a  cutting  edge ;  Prof.  Smith's  forceps,  for  cutting  into  the  stone 
when  too  large,  and  the  usual  lithotript  forceps  when  needed. 

With  these  instruments,  I  would  perform  the  lateral  operation 
always  when  practicable ;  when  stone  is  very  large,  the  bilateral.  I 
next  prefer  the  median  section  with  dilatation  and  lithotriptsy.  I 
do  not  believe  in  lithotriptsy  in  the  male,  through  the  urethra. 

For  the  left  lateral  incision,  I  prefer  the  grooved  staff  turning  to 
the  left,  that  is  the  curved  lateral  staff  of  Dr.  Nathan  E.  Smith, 
of  Baltimore,  and  with  its  movable  cap  and  rod  for  the  point  of  the 
gorget,  so  as  to  always  show  if  the  gorget  is  in  its  right  place.  The 


NEW   SURGICAL  INSTRUMENTS.  131 

angular  curved  staff  is  also  preferred,  and  I  also  prefer  the  angular 
blade  fixed  to  the  stafp  to  make  the  external  incisions,  making  a 
smoother  and  more  direct  cut  into  the  urethra  than  can  be  possibly 
done  with  a  knife  unattached. 

The  lithotome-cache  has  an  advantage  over  the  gorget.  It  cuts 
from  within  to  without,  and  thereby  prevents  any  laceration  of  the 
parts,  but  has  the  great  objection  that  its  blade  has  to  be  opened  in 
the  bladder,  and  might  cut  its  folds,  or  hook  and  cut  the  perito- 
neum, as  in  the  case  of  the  French  Marshal,  causing  infiltration  and 
death ;  but  through  a  small  perineal  section  I  think  it  necessary 
and  useful.  I  prefer  crushing  the  stone  to  making  a  bilateral 
incision,  for  fear  of  producing,  as  before  stated,  impotency  in  the 
patient. 

With  the  above  improved  instrument,  lithotomy  is  one  of  the 
safest  and  most  easily  performed  operations  in  surgery,  the  greatest 
trouble  being  the  insertion  of  the  stafi".'  By  the  median  section 
we  have  no  hemorrhage,  but  from  laceration  we  may  have  pyaemia 
and  erysipelas,  when,  if  we  performed  a  smooth  section,  it  would 
not  occur ;  and  by  the  median  section  I  think  there  is  more  danger 
of  wounding  the  rectum  than  in  the  lateral  operation. 

The  causes  of  death  after  lateral  lithotomy  are  the  following  :* — 

1.  Death  from  the  shock  of  the  operation,  without  any  discover- 
able lesion,  may  occur,  as  in  any  of  the  ordinary  operations;  it  is 
very  unfrequent,  generally  occurring  in  old  people,  and  sometimes 
in  children ;  it  seems  to  depend  upon  some  peculiar  condition  of 
constitution  and  nervous  system. 

2.  Death  from  chloroform  may  likewise  occur,  and  the  same  re- 
marks as  just  made  about  shock  apply  to  these  cases.  Lithotomy 
in  nowise  militates  against  the  use  of  ansesthetics. 

3.  Death  from  hemorrhage  and  exhaustion  may  ensue,  either 
primarily,  immediately  after  the  operation,  or  secondarily  some 
days  after,  from  separation  of  the  plug  of  coagulum  in  the  wounded 
vessel,  or  separation  of  a  slough  from  a  bruised  vessel,  or  the  ex- 
tension of  a  sloughing  wound  involving  the  vessels.  Death  from 
primary  hemorrhage  rarely  occurs,  and  although  children  can  little 
stand  any  great  amount  of  loss  of  blood,  yet  we  sometimes  see 
them  rally  after  having  been  thoroughly  blanched,  and  in  an  ap- 
parently hopeless  condition.  Listen  states  that  the  average  is 
about  one  death  in  one  hundred  cases.     M.    Begin  affirms  that 

*  Guy's  Hospital  Reports,  vol.  2,  p.  25» 


132  OEIGINAL   COXTRIBUTIONS   TO   OrEEATIVE   SUEGERY. 

it  is  the  cause  of  death  in  one  out  of  every  four ;  but  this 
is  not  so  in  this  country.  Although  primary  and  secondary  hem- 
orrhage may  not  per  se  cause  death,  yet  it  will  so  act  as  to  cause 
great  constitutional  depression  and  debility,  and  consequently  pre- 
vent the  reparative  process,  and  lay  the  foundation  for  general 
decline,  or  place  the  patient  in  a  condition  favorable  for  pyasmia. 

Death  from  pelvic  cellulitis  is  by  far  the  most  frequent  in  adults. 
It  consists  in  an  acute  inflammation  of  the  tissues  around  the  out- 
side of  the  bladder,  more  especially  the  neck,  base  and  sides ;  and 
is  generally  produced  by  urinary  infiltration  into  the  cellular  tissue 
of  the  pelvis.  Some  consider  it  to  be  due  to  too  great  a  section  of 
the  prostate,  involving  the  deep  pelvic  fascia,  and  allowing  the 
urine  to  pass  directly  into  the  cellular  tissue,  and  thus  cause  the 
inflammation ;  others  maintain  that  the  infiltration  of  the  urine  is 
not  a  mechanical  process,  but  generally  follows  inflammatory  action, 
and  that  this  inflammation  is  due  to  mechanical  violence  inflicted 
in  removal  of  the  stone,  from  insufficient  section  of  the  gland.  In 
some  instances  death  has  taken  place  from  cellulitis,  quite  inde- 
pendent of  urinary  extravasation.  This  inflammation  may  extend 
by  contiguity  to  the  peritoneum,  inducing  peritonitis ;  but  it  gen- 
erally leads  to  purulent  infiltration,  deposits  of  pus,  and  pysemia. 
The  symptoms  are  those  of  severe  constitutional  irritation,  attended 
with  rigors,  great  prostration  and  anxiety,  and  soon  followed  by 
symptoms  of  low  t3^phoid  fever ;  the  wound  assuming  an  unhealthy 
aspect,  and  giving  exit  to  a  fetid  discharge. 

5.  Death  from  acute  peritonitis  per  se  is  rare,  seldom  occurring 
in  adults,  but  now  and  then  in  children  where  the  anatomical  posi- 
tion of  the  bladder  is  closer  to  the  peritoneum,  so  that  too  large  a 
section  of  the  neck  and  base  of  the  bladder  may  involve  it.  Peri- 
tonitis used  formerly  to  be  considered  as  the  most  frequent  cause 
of  death  after  lithotomy,  but  subsequent  investigations  have  dis- 
proved this. 

6.  Death  from  acute  inflammation  of  the  mucous  membrane  of 
the  bladder  (cystitis),  extending  to  the  kidney  or  peritoneum,  is 
also  rare,  although  Boyer  has  asserted  it  to  be  the  cause  of  three- 
fourths  of  the  deaths ;  this  is  not  the  case. 

7.  Death  from  inflammation  of  the  prostatic  veins  (phlebitis)  and 
its  efiects  are  not  unfrequent,  and  generally  occurs  in  persons  of 
advanced  Ufe  ;  the  disease  does  not  often  set  in  until  after  a  week 
or  a  fortnight,  when  recovery  is  hopefully  anticipated. 


NEW   SUEQICAL   INSTRUMENTS.  133 

8.  Deatli  from  pyelitis,  or  inflammation  of  the  kidney,  or  suppu- 
ration of  the  kidney,  has  been  also  occasionally  met  with ;  and  at 
the  post-mortem  examination  the  advanced  state  of  the  disease  has 
given  evidence  of  its  having  existed  long  prior  to  the  operation. 

9.  Death  may  also  occur  from  absorption  of  the  products  from 
the  urine,  thus  poisoning  the  blood  and  causing  rapid  death. 

Erysipelas,  diarrhoea,  fever,  or  any  other  accidental  attack  may 
render  the  operation  fatal. 

Many  statistical  inquiries  have  been  made  respecting  the  mor- 
tality after  the  lateral  operation  of  lithotomy.  These  have  been 
recorded  by  Crosse,  Civiale,  South,  Coulson,  and  others,  to  whose 
works  we  must  refer  those  of  our  readers  anxious  to  investigate 
the  subject.  For  the  most  part,  these  statistics  cannot  be  relied 
upon  as  offering  any  direct  assistance,  except  so  far  as  a  general 
survey,  in  estimating  the  value  of  the  operation ;  they  comprise 
compilations,  selections,  and  returns,  in  which  are  many  faults  of 
omission  and  commission.  This  has  been  alluded  to  by  Mr.  Henry 
Thompson  {pp.  cit.),  who  has  attempted  to  lay  before  the  profession 
a  more  correct  table,  and  this  may  be  used  as  a  tolerably  complete 
epitome  of  the  mortality  of  lithotomy  under  British  surgeons ;  it 
is  derived  from  reliable  sources,  mentioned  in  the  text  of  his  work, 
and  contains  1827  cases. 

Mortality  Rates  at  all  Ages  in  1827  cases  of  Lateral  Operation,  in  Metropolitan  and 

Provincial  Hospital. 

GctSGS 

Norwieh  (Crosse) 669 

Since  that  time 124 

Oxford 110 

Leicester 90 

Leeds .29 

Birmingham 102 

Guy's  Hospital 230 

St.  Thomas'  Hospital        ...  200 

IFniversity  College  Hospital        .         .  90 

Cambridge 183 

Total 1827  229  nearly  1  in    8 

Some  have  based  the  rate  of  mortality  on  the  weight  of  the  stone 
(see  Crosse),  and  have  drawn  a  conclusion  that  the  mortality  in- 
creases in  nearly  the  same  ratio  as  the  weight. 

Others,  and  perhaps  with  more  reason  and  practical  tendency, 
have  considered  the  mortality  in  proportion  to  the  different  ages  of 
the  patients.  This  also  has  been  done  by  Mr.  Thompson  in  the 
following  table.  Still,  even  this  method  is  open  to  objection,  inas- 
much as  a  stone  may  have  been  formed  in  the  bladder  and  have 
remained  there  a  long  time  previous  to  the  operation. 


Deatlis. 

Cases. 

91                      about  1  in   7i 

15 

'      1  in    8i 

14 

'      1  in    8 

8 

'       1  in  11 

4 

'      1  in    7i 

10 

'      1  in  10 

33 

'      1  in    7 

29 

'      1  in    7 

12 

'      1  in    7i 

13 

'      1  in  14 

134 


OEIGINAL    CONTEIBUTIONS   TO   OPEEATIVE   SUEGERY. 


Mortality  Rates  of  Different  Ages. 


During  the  years 

1  to    5  inclusive 
5  to  11 

12  to 

17  to  20  " 

21  to  29  " 

30  to  38  " 

39  to  48 

49  to  bS  " 

59  to  70  " 

71  to  81  " 


Cases. 

Deaths 

473 

33 

377 

16 

178 

19 

76 

11 

m 

11 

75 

7 

100 

17 

191 

40 

233 

63 

38 

12 

Cases, 


about  1 

iu 

14i 

in 

23* 

m 

9i 

in 

7 

in 

8 

in 

lOi 

in 

6 

in 

4« 

m 

•di 

in 

■dk 

Total 


1827 


229 


We  have  taken  tlie  liberty  to  make  a  slight  modification  of  the 
above,  so  as,  if  possible,  to  show  the  mortality  at  the  different 
epochs  of  life,  which  may  guide  us  in  some  measure ;  but  it  is 
somewhat  arbitrary : — 


Mortality  Rates  at  Different  Epochs  of  Life. 


1  to  5,  infancy  and  childhood,  473  cases, ' 

33  deaths,  about  1  in  14J  cases    .     .     (^ 

6  to  11,  boyhood,  377  cases,  16  deaths,  I 

about  1  in  23*       .        .        .        .         J 

12   to    16,  boyhood,  with  increasing  de- ) 

velopment  and  setting  in  of  puberty.  J 

17  to  29,  adolescence  and  manhood  . 

30  to  48,  adults 

49  to  70,  advancing  life       .... 
71  to  81,  advanced  life    .... 

Total 


Cases. 


Deaths. 


Cases. 


850 

49 

about  1  in  174 

178 

19 

1  in  9i 

162 

22 

1  in  n 

175 

24 

1  in  74 

224 

203 

1  in  44 

38 

12 

1  in  34 

1827 


229 


average  nearly  1  in  8 

"We  have  inserted  a  table  drawn  up  by  Mr.  C.  Williams,  com- 
prising the  cases  operated  on  at  the  Norfolk  and  Norwich  Hospi- 
tal, during  a  period  of  ninety  years  ending  December  1862 : — 


Age. 

on 

3 

s 

Mortality 

S 

J2 

'6 

ft 

Mortality. 

CD 

a 
0 

1 

a, 

0 

6 

s 

Mortal'y. 

O 

306 

o 

0 

— 

1  to  10 

328 

22 

1  in  14.90 

) 

10  "  14 

55 

53 

2 

1  "  27.5 

U55 

421 

34 

1  in  13.38 

-\ 

14  "  20 

72 

62 

10 

1  "  7.2 

) 

1  574 

534 

42 

1  in  13.6. 

20  "  30 

59 

55 

4 

1  "  14.75 

1  119 

1 

30  "  40 

60 

56 

4 

1  "  15 

111 

8 

1  "  14.87 

40  "  50 

58 

47 

11 

1  "  5.27 

(190 

50  "  60 

132 

108 

24 

1  "  5.5 

155 

35 

1  "  5.42 

) 

60  "  70 

119 

87 

32 

1  "  3.71 

J  146 

^336 

a6o 

76 

1  in  4.42. 

70  "  80 

27 

18 

9 

1  "  3 

105 

41 

1  "  3.56 

i 
910 

792 

118 

910 

792 

118 

lin  7.71 

910 

792 

118 

lin  7.71 

1  in  7.71. 

869  were  males,  of  whom  811  were  operated  on  by  the  lateral 
method,  with  a  mortality  of  105  ;  41  by  the  median  section,  with 
death  in  11  cases ;  and  17  were  lithotritized  ;  41  were  females,  of 
whom  2  died. 


NEW   SURGICAL   INSTRUMENTS. 


135 


't.S 


■§  'S 


B<  s 


^ 


-^^  d 


•s  §  h  w 


.§    h 


."S    *= 


i.g 


s  ^ 


^     ►O     'O 


-2      ^ 


a 

'C 

O 

g 

« 

.rH 

o 

o 

O 

0) 

ai 

&( 

\ji 

A 

a 

si 

t> 

-d 

a    'r^ 

03 

1;l  2 

O 

t.  fe 

-d 

S-^ 


.3  a 

> 

o 

a 

0) 

O    05 

iH 

-i 

3 

a    ^ 

a> 

a  -d 


-  *-^  oj       op 
Ph  O  -Ji        -t^   .2     a? 


,-, 

cS 

a> 

S2 

is 

t3 

O) 

o 

a 

« 

CP 

^1 

> 

ft 

^j 

o 

o 

^-^ 

a 

'Titrt 

2i 
'a 

S 

to 

9 

-2  g  ^ 

.  cS  ^    o 


o3 

■d 

M 

•  •* 

4) 

a 

03 

OJ 

o 

<o 

ja 

■d 

2 

0) 

_d 

D,-d 

d 

^ 

•^ 

^ 

•ii 

-•-• 

u 

«d 

03^ 

-^ 

OJ  X) 

d 

d 

a 

^ 

03 

-►^ 

Tl 

MJ 

Oj 

fr! 

73 

a 

O 

c3 

ft 
O 

CJ 

d 

ft 

ft  d'd 
11^ 


-  ^^    a 


a  s  c 


as 

2rd 

T3T3 

a 

^  » 

1i 

cS 

^3 

a^ 

•S  n 

^ 

-B  fl 

^  o 

-73 

d 

t*- 

p    - 

^2 

to 

>  2 
otj:| 

o 
o 

QJ 

d 
o 

a) 

d 
o 

% 

■5  a 

-^    S-, 

rd=2 

d 

"^   m 

J  a> 

.2 

td 

d  & 

11 

a  i< 

o 

!>, 

rt  ?> 

.rt 

c3 

d   tn 

o3   ^ 

ft 

&: 

.2  <u 

03 

Oj 

"S-^, 

^   ^ 

d  a 


gj      O      ft  43    OJ      J^ 


rd     ^' 


d  a<  o   d 

a 

60 


d   ft 'O  ft 


a 


r^   '^ 


£  ^      2  dS 

13    03  a3'3 

■XJ  03    •  ts  a  J5 
-g  ft^'S  g  >. 

03  >    =S         'T3 

'S^^Sdg 

c*  &  d  Id  o  s 

§«d?g4JgS 

fttu  a 


a  s  -^'^"3 


0_t3    03    '-^  t< 


^  in   a  a 


a  a  43   g   ?  a  « 


03    O 


o.i5 


o  o3  ;5 


bjo   ^    03 


-5  ^  .2  03  ft  .ti 

S         "*!:?  y    03     03 

°  a;=^  ^^  S. 

rd  (U  to  ti_|      .rt 


S  i;^  S  d     A,    a 
cs  03  -ti  3J  a       =3 


03    »    03 

o  a^  i^ 

03'^^      "^ 


aim503'-3<^V.ig 
a   „,  V   03  o3  05   O  ^H 

„    a    03    03^^-^ 

dg5J§§"--S 
fr  2 


.s  o. 


si  o' 


g  o 


03=«ail5ft03     ftg    03    ^=d^ta    «d      03 


o  o  a  ^a 
i<    ft  y  ^H  g 


Sy=i-§-- 


H     o 


d    d  ^ 
O  O  Ph 


J3  -d    d 


O      H      H  HO      O  <i  O      O 


.2    ^^ 


■73   173        T3   'O   'C 


rii 


ffi 


to   to 


'to'to  to 


'to    to    tio'toio     'tOfli'tO    ffJ 


to    to      tOtWJ^^O     tK)^tfOtOtO      y^tOtO      tO 


(Ti 


[  iC     00 
.-I      -sh 


CO'*  '^ 

T  t-  Ol 


TjH  -5i<  00      rM 


CO  CO  ^ 


I  I— 1     (M        CO  ^  O 


t^      OD  05  O 


136 


ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 


O    pT 

.-  o 

-^^ 

e  >, 

CO  ^ 


-*^t3   o   m   ^ 
tw;^   OS   iJ   _ 


&:  b  Is  a 


2  a 


}-i   ,—i<^- 


Ti-- 


a  ^ 


s  a- 


CO  -t^ 

2   «^ 


o    -^-a 


a>  co'  §  £!  o3  2  .o 

-o  -2  2  -2 .2- a '*^ 


•o    CD    ft  2 

as  .iTs  §-  "^te  ^J- 

^  »3:3'S,=«^  St^  S^  a  g-s:S    5  2  s  ;= 

§_g-§  ^:n5  a  g  a  §  s 


"S 

ID     " 

a,  2 

p, 
© 

03    w 

-M 

fc-a 

a^a 


9  v     '^—1 


a  5 


P,q 


1^2 

o  « 

S3 


'^®"=«ti's«^§Z.'flasZ 

-  — "  trt  "-3       'sj  to  -p  .-  ..    ,,  ^  o 

^^    n3    C    ^    'I  -^  ' 


«;3 

o  'C 

■rH      ^ 


03  a 


OS'S 


Pho3 


"^  ft 

'«  03 
ft.„ 
ft  w 

Oj    0) 


?r:S     " 


fl  o 


« 


g  o    «>  be     ra" 


SoS2'^'S®.2««i< 
usi     r^  ft-S-c  5  n  oj 


>  o 


OS. 


-3 .3  a 

__    03 , 


^    J£  03    0),-.  '" 

"^-S  ==*£  ^g  '*-' 

be." 


a  s 


oj  S  Jr^«  i 


i.2"" 

•i   oS   03 

+;    0  73    te 

£3 


|^2l.s|§o3lsf^ 


o3  • 


.2-"    Oh 


0.a 

03  .tJ 


"^     '--S   03- 


S-^  9    Is  ^ 


-d  a>  £■ 


03,0) 


Cj 


a  &  » 
^.2 


2  S  9  o 


.^  5"  '*' 


3'Otrt   <v 


Jie 


S^a  g  03  o  ^0.  g  §^ 


03  l> 


a3  *-^ 

to  _  t»H  tJ 


,£  feJTS   o3^~^   '-OJ-tS 

^".§.2|i^§||-|^J 

'g'2  ^■a  s^  s-c  g^i^  ^  §  a 

S9-«-1^<U3"-Co3g<j,o3S(=-g 
■r5    rl    03  -fS  rj 


fl  §  03 

S  S  aj 

ri«!  CO  rt 

2  aj  § 

'  ^  2 

.  +i  to  ej 


ft  y 


O) 


d     -  03 

o  a  « 

go 

ft  o 
O    O) 


-IJ  O    IB 

CO  t» 

iH  (V     <U 

ed  '-'^ 

"^  a^ 


«  2  il"? 

.rH      rt    -ua     ft 

™    o    ■" 


•—I  » 

03   03 


■g     O   ©■ 


-d  ftd 


d     ja 
O     H 


<r>  ^  a>  ^ 


.^■g^ah.ts 

a>  03  ft 


S  -^  d' 


-Hdiaao 


05    S     d 

d  §  o 


s^^s^sad 


'd^  §  3-^  a  a-^ 


c3 


d  2 -i^ 

oj'j-  d 

d  ■» 

>  s 


^    (D    S 


aj  o  • 


■<£  to  -^  a;  1) 

S  C3  d    d     d 

^  "  „    in    o 

O  -fj  o3  _2  -i^ 


'O^'O-. 


1^ 

o   o 


o  ^ 


3 

00 

(TTi 

w 
w 

•^ 

■J? 

la 

«o 

to 

to 

tB 

O) 

to 

Oito 

to     . 

t+o    to 

d 

>. 

;^ 

Irt* 

1 

o* 

> 

;j? 

ffi 

t> 

rr^.^ 

O 

S 

to 

NO 

to 

to 

to 

to  to 

rti 

to    fTj 

NEW   SURGICAL   INSTRUMENTS.  137 

Eemarks  by  Mr.  C.  Williams.—  From  the  opening  of  the  IsTorfolk 
and  Norwich  Hospital,  in  1772,  to  November,  1863,  there  have 
been  admitted  923  cases  of  stone  in  the  bladder,  and  these  have 
undergone  some  form  of  operation  for  the  removal  of  the  complaint  ; 
twenty-four  of  this  number  suifered  a  relapse,  and  underwent  a 
second  operation.  The  proportion  that  such  cases  bear  to  the  whole 
number  of  stone-patients  is  one  in  38.45. 

The  two  cases  (Nos.  25,  26),  on  whom  lithotrity  was  first  per- 
formed, and  subsequently  lithotomy,  may  be  excluded  from  our 
consideration,  inasmuch  as  it  is  very  possible  that  fragments  of  cal- 
culus material  were  retained  in  the  bladder,  and  became  the  nuclei 
of  fresh  formations ;  an  occurrence  not  so  likely  to  happen  when 
lithotomy  was  resorted  to  in  the  first  instance. 

Our  table,  then,  presents  us  with  twenty-four  cases  of  recurrence 
of  stone,  taken  in  the  order  in  which  they  presented  themselves  at 
the  hospital ;  of  this  number,  nineteen  were  cured,  and  five  died ; 
three  had  stone  a  third  time,  two  were  cut  and  recovered,  the  third 
was  deemed  unfit  for  operation.  All  the  patients  were  males,  no 
instance  having  shown  itself  of  recurrence  in  the  female.  One 
patient  (No.  19)  underwent  lithotrity  for  his  second  operation,  and 
was  successfully  cured. 

Six  of  the  cases  were  below  ten  years  of  age ;  two  between  ten 
and  twenty ;  one  between  twenty  and  thirty ;  four  between  thirty 
and  forty;  two  between  forty  and  fifty ;  two  between  fifty  and  sixty; 
and  seven  between  sixty  and  seventy.  One  death  occurred  below 
forty  years  of  age,  and  four  above  that  period  of  life. 

The  production  of  the  second  calculus  took  place  in  six  of  the 
cases  within  one  year ;  in  ten  within  two  years ;  in  two  within 
three  years ;  in  one  within  four  years ;  in  one  within  five  years ;  in 
two  within  seven  years ;  while  in  the  remaining  two  cases  the 
operation  did  not  become  again  necessary  until  after  a  lapse  re- 
spectively of  nine  and  twelve  years. 

The  average  period  of  recurrence  in  the  twenty- four  cases,  was 
thirty-three  months.  Lateral  lithotomy  was  adopted  in  all  the 
patients  with  the  exception  of  eight,  two  of  which  were  cut  on  both 
occasions  by  the  median  plan ;  and  on  four  that  form  of  operation 
was  resorted  to  at  the  second  time. 

In  fourteen  the  calculi  were  removed  in  a  perfect  and  entire  con- 
dition at  the  first  operation ;  while  in  eight  the  calculi  were  broken 
in  the  extraction  ;  in  one  the  stones  were  very  small  and  numerous : 
10 


13S  ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 

and  in  the  remaining  one,  a  sacculated  stone  was  left  undetected  in 
the  bladder. 

It  does  not  appear  that  the  second  calculus  is  necessarily  of  the 
same  character  in  all  cases  as  the  first,  though-  in  sixteen  the 
second  formations  were  of  the  same  composition  as  the  first ;  nine 
being  composed  of  the  phosphates,  seven  of  lithic  acid  and  the 
lithates ;  whilst  the  phosphates  succeeded  the  lithates  in  five,  and 
the  oxalates  in  two. 

Such  are  the  practical  points  in  connection  with  ordinary  lateral 
lithotomy.  We  shall  now  cursorily  allude  to  the  several  other  modes 
of  proceeding  in  the  perineal  section,  as  adopted  in  this  country 
and  elsewhere. 

1.  Lateral  lithotomy  modified  as  regards  the  section  of  the  pros- 
tate ;  Royer  made  a  transverse  incision  of  the  prostate  with  the 
lithotome-cache,  dividing  the  gland  in  its  greatest  diameter ;  but 
the  objection  to  the  operation  was  the  division  of  the  perineal 
vessels,  and  consequent  hemorrhage.  Senn  combined  the  two,  by 
making  the  ordinary  oblique  incision  through  the  left  lobe,  and  the 
transverse  one  through  the  right. 

2.  The  perineal  incision,  made  in  a  transverse  direction,  and  of  a 
semi-lunar  curve  in  front  of  the  anus.  This  was  advocated  by 
Dupuytren  in  his  well-known  bilateral  section  of  the  prostate  gland 
in  cases  of  large  stone.  He  divided  the  tissues  toward  the  sym- 
physis, so  as  to  avoid  the  rectum,  the  urethra  was  opened  from 
above  downward  (median)  with  a  double-edged  bistoury,  and  then 
his  curved  double  lithotome  was  introduced  into  the  bladder ;  the 
blades  were  then  opened  and  made  to  cut  their  way  out,  dividing 
the  prostate  in  its  oblique  diameters.  The  results  of  this  operation 
gave  nineteen  deaths  in  eighty-five  cases,  or  one  in  four  and  a  half 
cases. 

3.  Median  lithotomy,  where  the  incision  is  made  in  the  central 
line  of  the  perineum,  formerly  known  as  the  Marian  operation. 
This  comprises  two  modes  of  proceeding,  viz.,  with  section  of  the 
prostate  gland,  or  without  section  of  the  gland,  by  merely  opening 
the  urethra,  with  perhaps  partial  division  and  incision  of  the  apex 
of  the  organ.  Vacca  was  the  first  to  revive  the  median  operation, 
and  he  practised  a  vertical  section  of  the  prostate ;  but,  although 
there  was  no  fear  of  hemorrhage,  the  rectum  was  endanG;ered,  so 
that  the  operation  could  only  be  performed  when  the  stone  was 
small  and  in  adult  prostates. 


NEW   SUEGICAL   INSTEUMENTS.  139 

Civiale,  in  1836,  modified  this  procedure  by  his  medio-bilateral 
operation.  Having  made  his  perineal  incision  in  the  median  line, 
he  avoided  the  bulb,  and  opened  the  membranous  portion  of  the 
urethra,  when  he  introduced  a  straight,  double-bladed  lithotome 
into  the  bladder,  and  by  withdrawing  it  opened,  made  a  transverse 
section  of  the  gland,  as  in  Beyer's  operation. 

Buchanan  has  further  simplified  this  method  by  the  following 
m.ode  of  proceeding :  he  uses  a  rectangular  staif,  which  is  one  bent 
at  right  angles  three  inches  from  the  point,  and  having  a  deep,  lat- 
eral groove,  with  a  posterior  opening.  The  instrument  is  intro- 
duced into  the  bladder,  assisted  by  the  left  forefinger  in  the  rectum, 
and  thus  the  angle  made  to  correspond  in  situation  with  the  apex 
of  the  prostate  gland,  the  lower  or  grooved  branch  lying  parallel 
to  the  rectum.  The  angle  rests  on  the  farthest  extremity  of  the 
membranous  portion  of  the  urethra,  so  that  when  the  knife  is 
plunged  into  the  groove  of  the  staff  the  membranous  portion  escapes 
all  injury.  The  staflP  is  entrusted  to  an  assistant,  and  the  operator, 
keeping  the  left  forefinger  in  the  rectum,  takes  a  long,  straight 
bistoury,  holding  it  in  his  right  hand  with  the  palm  upward,  the 
blade  horizontal,  and  the  edge  directed  to  the  left ;  he  then  enters 
the  perineum  opposite  the  angle  of  the  stafi",  and  passes  the  knife 
straight  into  and  along  the  groove,  as  far  as  the  stop  at  its  extrem- 
ity, into  the  bladder.  Next  he  withdraws  the  bistoury  slowly, 
making  a  lateral  section  of  the  prostate,  but  as  he  does  so  cuts 
outward  and  downward,  a  distance  rather  more  than  equal  to  about 
one-fourth  of  a  circle  round  the  upper  and  left  side  of  the  rectum, 
in  which  organ  his  finger  still  remains ;  an  external  wound,  sur- 
rounding the  corresponding  part  of  the  anus  about  one  and  one- 
quarter  inches  in  length,  results  from  the  operation.  His  arguments 
in  favor  of  this  procedure  are :  1.  The  more  easy  and  rapid  method 
of  reaching  the  prostate  gland,  being  only  two  lines  from  the  sur- 
face of  the  skin,  the  rectum  pressed  out  of  the  way,  and  the  knife 
passed  straight  forward  into  the  bladder.  2.  The  membranous 
portion  of  the  urethra  is  avoided,  and  less  incision  required ;  all 
blood  vessels  are  out  of  the  way,  and  consequently  there  is  no  hem- 
orrhage. 3.  The  rectum,  notwithstanding  its  vicinity  to  the  inci- 
sion, is  less  likely  to  be  injured;  and  4.  There  is  less  risk  of  deep- 
seated  infiltration  of  urine. 

AUarton's  operation  is  also  performed  in  the  median  line,  but  he 
does  not  make  any  section  of  the  prostate  gland,  except  it  be  but 


140         ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SUROERY. 

partial,  just  incising  tlie  apex.  The  ordinary  staff  is  introduced 
into  the  bladder,  and  then  the  left  forefinger  passed  into  the  rectum, 
so  as  to  feel  the  staff  at  the  prostate  :  he  transfixes  with  a  straight 
bistoury  the  perineum  in  the  median  line  about  half  an  inch  above 
the  anus,  carrying  the  knife  on  till  it  strikes  the  groove  of  the  staff 
at  the  membranous  portion  in  front  of  the  prostate ;  the  urethra  is 
pierced  at  this  spot,  and  after  pushing  the  knife  toward  the  bladder 
for  a  few  lines,  it  is  withdrawn,  at  the  same  time  cutting  upward, 
dividing  the  urethra  a  little,  and  finishing  so  as  to  have  an  external 
incision  of  three-fourths  to  one  and  one-half  inches.  A  long,  ball- 
pointed  probe  is  then  passed  into  the  bladder  along  the  groove  of 
the  staff,  when  the  latter  is  withdrawn,  and  the  left  index-finger 
slided  along  the  probe  into  the  bladder,  dilating  the  prostate  and 
neck  of  the  bladder  to  the  requisite  extent,  and  serving  as  a  guide 
to  the  forceps.  Where  the  stone  is  large  he  uses  Weiss'  three- 
bladed  female  director,  or  Arnott's  hydraulic  director. 

In  cases  of  large  stone  Vidal  de  Casis  has  advised  a  quadrilateral 
section  of  the  prostate  gland ;  he  says,  "  no  matter  what  kind  of 
external  incision,  as  long  as  it  is  not  too  small,  whether  it  be  trans- 
verse, oblique^  vertical  or  curved ;  the  point  in  view  is  to  have  one 
large  external  incision,  and  many  small  internal  ones.  The  two 
first  sections  of  the  prostate  are  to  be  made  along  the  two  inferior 
oblique  diameters  of  the  gland,  which  will  be  sufficient  when  the 
stone  is  of  moderate  size ;  but  when  large,  the  two  superior  oblique 
divisions  are  to  be  made,  first  one  and  then  the  other." 

We  shall  now  pass  on  to  lithotomy  through  the  rectum — the  recto- 
vesical operation.  This  has  been  recommended  in  consequence  of 
its  supposed  readiness  of  performance,  and  the  easy  passage  of  in- 
struments, besides  being  free  from  hemorrhage.  The  operation 
consists  in  placing  the  patient  in  the  same  position  as  for  ordinary 
lithotomy ;  a  grooved  curved  staff  is  then  introduced  into  the 
bladder,  and  held  by  an  assistant  firmly  and  perpendicularly,  so 
that  the  groove  is  in  the  median  line.  The  operator  takes  a  sharp- 
pointed,  straight  bistoury  in  the  right  hand,  resting  the  blade  flat- 
ways on  the  palm  or  surface  of  the  left  forefinger,  which  latter  is 
then  introduced  into  the  rectum  to  the  extent  of  ten  or  twelve 
lines.  With  the  right  hand  the  edge  of  the  knife  is  turned  up- 
ward, and  its  point  thrust  through  the  anterior  wall  of  the  rectum, 
so  as  to  gain  the  groove  of  the  staff,  and  as  the  knife  is  withdrawn, 
it  cuts  through  the  rectum,  the  external  sphincter  and  cellular 


NEW   SURaiCAL   INSTRUMENTS.  141 

tissue  covering  the  urethra  and  integument  in  the  median  line,  to 
the  extent  of  one  inch.  The  left  forefinger  is  next  carried  into  the 
wound  of  the  sphincter,  and  the  nail  inserted  into  the  groove  of 
the  staff,  when  the  bistoury,  with  its  edge  downward,  is  guided 
along  it  through  the  wall  of  the  urethra  into  the  groove,  and 
pushed  in  the  direction  corresponding  to  the  raphe,  dividing  the 
neck  of  the  bladder  and  the  prostate  to  a  greater  or  less  extent, 
according  to  the  presumed  size  of  the  stone ;  the  staff  having  been 
removed,  the  finger  is  introduced  into  the  bladder,  and  the  calculus 
extracted  by  the  forceps. 

The  drawbacks  to  the  operation  are  the  gliding  of  the  mucous 
membrane  of  the  rectum  before  the  knife,  the  great  risk  of  wound- 
ing the  peritoneum  and  vesiculse  seminales,  the  subsequent  occur- 
rence of  urinary  infiltration,  the  passage  of  fseces  into  the  bladder, 
fistulous  sinuses,  etc.  Of  185  cases  operated  on,  38  died,  being  1 
in  4.86 ;  but  the  subsequent  condition  of  those  who  recovered  is 
not  stated. 

The  hypogastric  or  high  operation.  Epicystotomia  is  considered 
by  some  surgeons  the  most  direct,  short  and  least  dangerous  opera- 
tion. Its  advocates  argue  that  there  are  no  technical  or  anatomi- 
cal difficulties,  with  the  exception  of  the  peritoneum,  which  is 
easily  avoided.  It  suits  all  sizes  of  stone,  enables  the  surgeon  to 
have  a  free  opening  into  the  bladder,  and  there  is  not  so  much 
danger  of  infiltration  of  urine  as  has  been  alleged.  The  wounding 
of  the  perineum  must  be  regarded  as  a  failure  in  anatomical  man- 
ipulation. Pith  remarks,  that  in  male  children,  and  young  persons 
below  twenty,  as  well  as  in  females,  the  bladder  stands  high  above 
the  pubes,  and  presents  an  uncovered  portion  freely  to  surgical 
manipulation  ;  under  eight  years  the  peritoneal  reflection  from  the 
bladder  does  not  generally  reach  lower  than  one  and  a  half  to  two 
inches  from  the  navel.  In  old  persons,  especially  when  emaciated, 
the  bladder  lies  deep  in  the  pelvis,  behind  the  symphysis,  and  is 
difficult  to  reach;  hence  the  impropriety  of  operating  by  this 
method  in  such  cases. 

Other  surgeons  maintain  that  there  is  great  risk  of  peritonitis, 
infiltration  of  urine,  and  wound  of  the  peritoneum,  and  that  the 
operation  is  only  applicable  in  cases  of  deformed  pelvis ;  and  where 
there  is  much  fat  it  is  rendered  very  difficult. 

The  old  method  was  that  of  Franco,  who  introduced  a  finger  into 
the  rectum,  and  pushed  the  stone  up  toward  the  hypogastrium,  and 


142  OEIGINAL    CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 

its  prominence  formed  the  guide  for  tlie  incision.  A  more  cautious 
proceeding  was  afterward  adopted.  The  preparation  for  the  opera- 
tion consists  in  emptying  the  rectum  and  distending  the  bladder, 
either  by  the  patient  retaining  his  urine,  or  by  injecting  a  sufficient 
quantity  of  tepid  water  to  produce  distention  without  over-excess, 
which  latter  is  best  performed  under  chloroform  at  the  time. 

The  patient  is  placed  on  the  back,  with  the  pelvis  raised,  and 
the  operation  is  performed  in  three  steps.  The  first  consists  in  lay- 
ing bare  the  anterior  wall  of  the  bladder,  by  a  vertical  incision  in 
the  median  line  immediately  above  the  pubes,  cutting  through  the 
linear  alba  and  fascia  transversalis,  and  exposing  the  loose  subfascial 
cellular  tissue,  in  which  some  fat  is  often  found. 

The  second  step  is  that  of  opening  the  bladder,  and  is  the  most 
important  part  of  the  operation,  requiring  the  greatest  precision 
and  care ;  the  opening  ought  to  be  made  close  to  the  symphisis,  and 
quite  in  the  median  line.  Some  surgeons  have  suggested  and  used 
an  instrument  called  the  sonde-a-darde,  which  consists  of  a  trocar 
concealed  in  a  catheter.  This  is  introduced  through  the  urethra 
into  the  bladder,  and  then  the  trocar  is  extruded  and  pushed 
through  the  fundus  of  the  bladder  at  the  external  opening.  This 
is  considered  both  imprudent  and  mischievous.  It  is  b^t  to  trans- 
fix the  bladder  through  the  wound,  and  thus  secure  it.  The  blad- 
der is  then  to  be  opened  by  a  median  incision  from  below  upward. 
A  few  authors  recommend  a  transverse  incision.  The  external  in- 
cision in  the  meanwhile  must  be  kept  open  by  retractors,  in  conse- 
quence of  the  tendency  of  the  parietes  to  contraction. 

The  third  step  consists  in  the  extraction  of  the  stone,  which  may 
be  readily  done  by  a  pair  of  straight  forceps. 

Civiale  uses  the  sonde-a-darde,  and  has  otherwise  modified  the 
operation. 

The  after  treatment  is  now  confined  to  simple  measures;  formerly 
a  gum  catheter  was  lef|i  in  the  bladder ;  others  made  a  counter- 
opening  in  the  perineum  to  drain  ofi"  the  water,  and  some  used 
sutures  in  the  bladder;  but  it  is  now  considered  more  judicious  to 
place  the  patient  in  bed  on  the  back  or  sides,  with  the  legs  drawn 
up,  to  employ  water-dressing,  and  nothing  else.  No  catheter,  no 
canula,  no  other  measure,  is  required. 

Vidal  recommends  the  operation  to  be  performed  "en. deux 
temps."  An  incision  is  to  be  made  in  the  median  line,  dividing  all 
the  tissues,  and  exposing  the  bladder ;  then  the  operation  is  to  be 
set  aside,  and  the  wound  filled  with  charpie,  which  is  to  be  replaced 


NEW   SURGICAL   INSTRUMENTS.  143 

daily,  so  as  to  prevent  union.  If  at  the  end  of  six,  seven,  or  eight 
days  there  be  abundant  suppuration,  the  operation  is  to  be  com- 
pleted by  opening  the  bladder  with  a  straight  bistoury,  and  extract- 
ing the  calculus. 

In  taking  a  general  survey,  or  making  any  critical  comparison 
of  the  various  principal  operations  and  modes  of  removing  a  calcu- 
lus from  the  bladder,  much  will  depend  upon  the  age  and  condition 
of  the  patient,  as  well  as  the  size  and  nature  of  the  stone.  In  the 
first  place,  the  great  point  will  be  to  determine  whether  the  case 
be  fit  for  the  operation  of  lithotrity.  This  subject,  however,  is 
alluded  to  in  a  separate  section.  When  lithotomy  is  determined 
upon,  there  can  be  no  doubt  for  a  moment  that  in  children  under 
twelve  years  of  age  the  lateral  operation  is  the  safest  and  most 
successful,  the  mortality  being  1  in  17:^  cases  only.  Of  course 
this  does  not  preclude  the  performance  of  the  median  operation, 
where  the  stone  is  small  or  even  of  moderate  size.  At  puberty 
and  adolescence,  and  in  manhood  and  adults  from  twelve  to  forty- 
eight  years,  the  mortality  of  the  lateral  operation  rises  to  nearly 
one  in  eight,  and  from  forty-nine  to  eighty-one  years  it  amounts  to 
one  in  four  cases.  It  is  in  these  periods  of  life,  then,  that  some 
other  modes  of  operating  have  been  suggested  to  lessen  the  mor- 
tality. Statistics  have  not  yet  shown  so  much  improvement  as 
might  be  anticipated.  Thus  in  Allarton's  median  operation. on  one 
hundred  and  thirty-nine  cases  at  all  ages,  thirteen  deaths  ensued, 
being  one  in  eleven;  and  when  restricting  this  to  adults,  the  mor- 
tality was  one  in  seven ;  and  in  Mr.  Williams'  report  the  mortality 
over  fifty  years  of  age  is  nearly  one  in  two  and  a  half.  Of  sixty 
cases  operated  upon  by  Buchanan's  method,  the  result  seems  to  be 
the  same  as  in  Allarton's  operation,  except  that  in  adults  the  mor- 
tality is  one  in  eight. 

The  bilateral  operation  of  Dupuytren  bears  a  death-ratio  of  one 
in  four  and  a  half,  the  recto-vesical  about  one  in  five,  and  the  su- 
pra-pubic one  in  three  and  a  half.  These  latter  proceedings  are 
only  had  recourse  to  in  cases  of  very  large  stone,  and  where  com- 
plications exist  preventing  perineal  lithotomy. 

As  far  as  our  present  information  extends,  the  median  operation 
may  be  performed  with  safety  in  cases  where  the  stone  is  small  ; 
but  the  lateral  operation  is  to  be  preferred  in  all  other  cases  where 
lithotrity  is  inexpedient. 

*  See  Thomson,  op.  ct.  p.  72. 


144         ORIGINAL   CONTEIBUTIONS   TO   OPEEATIVE   SIIEGERY. 

The  main  issue,  as  regards  the  success  of  any  one  form  of  opera- 
tion, seems,  after  all,  to  be  chiefly  dependent  upon  the  mode  of 
enlarging  the  opening  of  the  urethra  through  the  prostate  and  the 
neck  of  the  bladder.  This  resolves  itself  into  one  of  two  proceed- 
ings ;  either  dilatation  of  the  prostate  and  neck  of  the  bladder,  as 
in  the  median  operation,  or  section  of  these  structures,  as  in  lateral 
lithotomy.  Is  it  safer  to  dilate,  bruise,  and  lacerate  the  prostate 
gland  and  neck  of  the  bladder,  or  to  make  a  clean,  careful  incision 
with  the  knife  ?  Small  stones  are  no  test  whatever  as  to  the  value 
of  either  mode  of  operation,  nor  are  calculi  in  children ;  for  in  the 
latter,  whichever  mode  is  adopted,  a  recovery  is  expected.*  It  is 
in  adults  that  we  are  always  trying  to  lessen  the  mortality  after  the 
lateral  operation,  and  none  of  the  recent  improvements  seem  to 
have  supplied  the  deficiency.  Even  in  Mr.  Allarton's  recent  table, 
p.  499,  2d  edit.,  his  mortality  is  one  in  seven. 

We  should  have  gladly  quoted  the  table  inserted  in  that  work, 
which  consists  of  one  hundred  and  seventy  cases  of  median  lith- 
otomy, but  these  do  not  in  the  least  represent  the  actual  state  of 
affairs ;  the  cases  are  for  the  most  part  taken  from  all  sorts  of  re- 
ports of  a  successful  issue;  many  known  cases  of  death  after  the 
median  operation  are  unrecorded ;  in  two  instances  the  author  him- 
self has  been  obliged,  in  consequence  of  the  size  of  the  stone,  to 
abandon  the  operation,  and  terminate  it  by  section  of  the  prostate 
gland ;  which  latter  proceeding  undoubtedly  led  to  the  successful 
termination.  Median  lithotomy,  therefore,  necessitates  the  bruis- 
ing and  laceration  of  the  prostate  gland,  in  cases  of  stone  above  a 
certain  size,  and  in  consequence  will  almost  inevitably  lead  to  a 
fatal  result.  The  lateral  section  still  maintains  its  position  as  the 
safest ;  it  was  so  with  Cheselden,  Crosse,  and  numerous  other  sur- 
geons. 

The  most  perfect  and  unique  collection  of  cases  of  the  median 
operation,  performed  at  a  hospital  of  well-established  reputation  for 
lateral  lithotomy,  will  give  more  insight  into  the  comparative 
merits  of  the  two  operations ;  and  we  gladly  avail  ourselves  of  the 
opportunity  of  presenting  to  our  readers  one  that  has  been  so 
formed.  By  permission  of  Mr.  Williams,  we  are  enabled  to  insert 
his   tables,  and  thus  compare  the  results  of  forty-four  cases  of 

*  Thus,  in  the  last  two  years,  at  Guy's  Hospital,  fifteen  children  under  fourteen 
years  of  age  underwent  lateral  lithotomy,  without  any  unfavorable  result ;  and  it  is 
not  improbable  that  median  lithotomy  might  have  been  similarly  successful. 


NEW   SURGICAL   INSTRUMENTS. 


145 


median  lithotomy  with  the  last  forty-four  current  cases  of  lateral 
lithotomy  performed  at  the  Norfolk  and  Norwich  Hospital  up  to 
November,  1863. 


Table  of  Cases  where  Median  Lithotomy  was  performed  at  the  Norfolk  and  Norwich  Hospi- 
tal; showing  the  age  in  years,  the  result,  the  number  of  days  under  care  after  the  opera- 
tion, the  number  of  calculi  removed  from  each  patient,  the  dimensions  and  weight  of 
each  calculus. 


jj 

c-g 

"3 

Dimensions  in  inches. 

JO 

■< 

6 

•WEIGHT  AND  REMARKS. 

Length. 

Bre'dth 

Depth. 

1 

2 

cured 

22 

t^ 

M 

H 

14  grains. 

2 

2^ 

>t 

35 

% 

% 

34  grains. 

8 

3 

" 

23 

14  grains. 

4 

3% 

•« 

29 

IVa 

Vs 

Vs 

2  drachms. 

5 

4 

(1 

29 

35  grains;  calculus  broken  in  the  extraction. 

6 

4 

" 

15 

16  grains;  calculus  broken  in  the  extraccion. 

7 

4 

" 

29 

Small  calculi ;  all  weighing  30  grains. 

8 

4 

" 

36 

1 

K 

% 

47  grains. 

9 

5 

" 

50 

15  grains. 

10 

5 

" 

22 

% 

M 

H 

2  scruples. 

11 

5^ 

" 

29 

8  grains. 

12 

6 

'* 

2'2 

1>|  drachms;  broken  in  the  extraction. 

13 

8 

" 

35 

I 

K 

K 

5  scruples. 

14 

l'>^ 

" 

16 

3  grains. 

15  11 

" 

21 

3  drachms  and  2  scruples;  all  of  them  broken 

during  the  extraction. 

16 

12 

" 

28 

6  grains. 

17 

13 

" 

29 

1  scruple;  broken  during  the  extraction. 

18 

19 

" 

56 

IVs 

1% 

% 

3  drachms,  10  grains;  a  perineal  fistula  was 
established. 

19 

33 

" 

22 

1 

\U  w 

m 

¥ .. 

2  drachms  and  10  grains. 

20 

33 

15 

2 

i-'Ai'A 

lYa 

y^Vs 

One  calculus  weighed  S  scruples,  the  other  not 
quite  6  scruples;  one  caiculus  ^vas  pear- 
shaped  and  encysted. 

21 

57 

29 

5 

1 

1 

Vt. 

Each  weighed  about,  2  drachms.  In  all  12 
drachms,  2  scruples;  each  calculus  of  the 
same  dimensions. 

22 

57 

" 

29 

1 

1^4 

iVa 

1 

3  drachms. 

23  59 

" 

16 

1 

IVs 

1 

t^ 

1  drachm,  13  grains. 

24 

60 

15 

4 

I'A 

1 

k 

Each  weighed  about  2  drachms,  all  weighed  8 
drachms;  the  largest  of  the  four  had  the  di- 
mensions given. 

25 

61 

" 

37 

1 

5  scruples  ;  broken  in  the  extraction. 

26 

61 

II 

31 

10 

All  weighed  3  drachms. 

27 

63 

69 

1 

2% 

2 

IK 

4  ounces,  5  drachms ;  a  recto-vesical  fistula  re- 
mained. 

28 

66 

(( 

42 

1 

22 grains;  broken  in  the  extraction. 

29 

66 

36 

5 

All  of  them  weighed  8  scruples.  This  was  the 
second  operation;  a  fistula  remained  after 
the  1st,  .which  was  cured  by  the  2d.  The 
same  case  as  No.  28. 

30 

67 

i> 

30 

1 

m 

^¥> 

t^ 

3  drachms,  2  scruples. 

81 

68 

" 

29 

2 

IVs 

Vs 

% 

Both  weighed  2  drHchms,  and  both  were  of  the 
same  dimensions. 

32 

70 

It 

22 

1 

2  scruples ;  phosphatic,  and  broken  In  the  ex- 
traction; a  perineal  fistula  present  from  a 
former  operation  (lateral). 

38 

72 

50 

1 

1  drachm;  broken  in  the  extraction.  The 
same  patient  as  No.  32.  The  fistula  was  not 
healed  by  either  1st  or  2d  operations. 

34 

o^^ 

died. 

1 

2 

Both  weighing  y^  drachm. 

35 

37 

>t 

13 

1 

1% 

VA 

Vs. 

7  drachms. 

36 

55 

3 

2 

Both  weighed  7  scruples,  and  were  broken  in 
the  extraction. 

37 

57 

" 

11 

1 

1% 

13^ 

1 

1  ounce,  2  scruples. 

38 

61 

9 

2 

I'AIA 

1^41^ 

%y4. 

One  calculus  weighed  5  drachms,  the  other  5 
drachms,  2  scruples. 

39 

62 

" 

18 

1 

IK 

1J4 

1 

6  drachms. 

40 

64 

86 

3 

All  broken  in  the  extraction ;  together  weigh- 
ing 10  drachms. 

41 

66 

" 

4 

1 

m 

1% 

1 

^y^  drachms. 

42 

66 

" 

2 

1 

2 

1^ 

1  ounce. 

43 

66 

*' 

4 

1 

2 

IK 

1 

12  drachms. 

44 

68 

i< 

14 

1 

6  grains. 

N.  B— The  weight  of  every  calculus  was  taken  on  the  day  of  its  removal. 


146 


ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 


AGES  OF  THE  PATIENTS. 

Under  5  years  of  age 9  cases 

From  5  to  10 5  " 

"     10  to  20 5  " 

"     20  to  30 0  " 

"     30  to  40 3  " 

"     40  to  50    ......     .  0  " 

"     50  to  60 5  " 

"     60  to  70 15  " 

"     70  to  SO 2  " 


44 


DEATHS  AFTER  MEDIAN  lilTHOTOMY. 

Under  5  years  of  age      ....  1  case 

From  30  to  40 1    " 

"     50  to  60 2    " 

"     60  to  70  ......     .  7    " 


11 


Table  of  the  Last  forty-four  Cases  of  Lateral  Lithotomy  Performed  at  the 
Norwich  Hospital. 


AGES  OF  THE  PATIENTS. 

Under  5  years 5  cases 

From  5  to  10 4  " 

"    10  to  20 4  " 

"    20  to  30 3  " 

"    30  to  40 3  " 

"   40  to  50 1  " 

"   50  to  60 8  " 

"    60  to  70 10  " 

"   70  to  80 6  " 


44 


DEATHS  or  THESE  PATIENTS. 

From  50  to  60 1  case 

"      70  to  80 1    " 


Average  number  of  days  that  each  of  the  thirty-three  cases  of 
cure  after  median  lithotomy  -was  under  care  was  thirty  days. 

Average  number  of  days  that  each  of  the  last  thirty-three  cases 
of  cure,  after  lateral  lithotomy  was  under  care  was  thirty-seven 
days. 

Table  of  the  Number  and  Weight  of  the  Calculi  Eem/yved  from  those  who  Died  after 
Median  Lithotomy. 


Under  5  years 1  calculus,  weighing  i  drachm. 

1  "  u         7        « 

J  2  calculi,  both  weighing  2  dr.  1  scr. 


From  30  to  40  years 
From  50  to  60  years 


From  60  to  70  years 


1  calculus,  weighing  1  oz.  2  scr. 


6grs. 

5\  drs. 

1  oz. 

12  drs. 

6  drs. 

1  oz.,  2  drs. 

10  drs.,  2  scr. 


Number  and  Weighs  of  the  Calculi  Removed  from  those  who  Died  after 
Lateral  Lithotomy. 

From  50  to  60  years,  1  case 1  calculus  Weighing  2  drs. 

From  70  to  80  years,  1  case 1        "  "        3  ozs. 

Remarks  by  Mr.  Williams  on  the  Cases  of  3Iedian  Lithotomy, 

Two  cases  were  cut  twice  by  the  median  plan,  at  intervals  of 
nine  and  four  months  respectively. 

In  no  case  did  recovery  result  when  the  calculus  exceeded  three 


NEW   SUEGICAL   INSTEUMEXTS. 


147 


draclims,  two  scruples;  except  in  one  case,  in  which,  the  stone 
weighed  upward  of  four  and  a  half  ounces,  but  a  portion  of  the 
rectum  and  perineum  sloughed,  and  a  pjerineo-recto-vesical  fistula 
was  established. 

In  no  case  did  a  cure  result  when  the  long  diameter  of  the  cal- 
culus exceeded  one  and  a  half  inches,  and  the  short  one  and  one- 
eighth  inch,  except  in  the  case  in  which  the  stone  weighed  upward 
of  four  and  a  half  ounces. 


New  Instrnments  for  Lithotomy  in  the  Male. 

Figures  43  and  44  show  the  in-  ^'^'  ' ' 

struments,  as  now  constructed  by- 
Mr.  Kolbe,  of  No.  15  South  Ninth 
street,  Philadelphia,  and  may  be 
thus  described :  Fig.  43  is  shaped 
like  Prof.  Nathan  Pt.  Smith's  sound, 
and  with  his  external  urethrotome. 
At  the  point  where  the  blade  of  the 
urethrotome  strikes  the  stafi",  there 
is  a  slit  for  the  blade  to  go  entirely 
through  the  staff;  and  just  in  front 
of  it  there  is  a  round  hole  for  the 
entrance  of  the  point  of  Fig.  44; 
and  from  this  to  the  point  of  the 
staff  there  is  a  fenestra  that  allows 
the  point,  when  passed  through  the 
hole,  to  slide  toward  the  bladder,  after  the  manner  of  the  bayonet 
hitch,  and  will  not  allow  the  instrument  to  slip  out,  or  to  the  right 
or  left,  being  held  there  by  its  rounded  point,  which  passes  through 
the  hole.     Figure  44  is  a  double  gorget,  with  movable  blades ;  by 

Fig.  44. 


Staff  and  External  Urethrotome. 


Gorget. 


unscrewing  the  little  screw  at  its  base,  either  the  right  or  left  blade 
may  be  taken  off,  and  then  it  becomes  a  lateral  gorget,  and  can  be 
used  for  either  side.     A  gorget  with  the  blade  immediately  under 


148  ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 

its  shaft,  is  made  to  perform  the  median  incision.  It  is  also  made 
movable,  in  order  to  have  it  sharpened.  With  these  instruments  I 
can  perform  lithotomy  well  and  safely,  blindfolded,  as  the  blades 
cannot  get  out  of  place,  to  the  right  or  left,  or  downward,  unless 
the  point  is  broken  off.  Any  one  who  can  insert  the  sound,  and 
has  anatomical  knowledge  enough  to  know  where  the  bulb  of  the 
urethra  is,  can  perform  this  operation  as  safely  as  any  lithotomist 
in  the  world.  I  claim  nothing  original  with  myself,  except  the 
modification  of  principles  invented  by  others.  The  shape  of  the 
staff  is,  as  I  said  before,  Dr.  Smith's.  The  fenestrated  groove  is  the 
invention  of  Prof.  Goodwin,  of  the  Galveston  Medical  College  ; 
but  his  instruments  had  these  objections :  his  sound  was  too 
straight,  and  could  not  be  held  well  up  under  the  pubis,  and  the 
median  incision  could  not  be  made  with  it.  His  gorget  was  bent 
at  the  blades  and  not  at  the  handle,  as  in  mine,  which  bend  pressed 
against  the  perineum  in  pushing  it  into  the  bladder,  and  the  bend 
of  the  handle  was  not  enough  downward  to  allow  free  motion  of 
the  hand.  His  blades  were  immovable  on  the  gorget,  and  did  not 
have  the  external  urethrotome  attachment,  which  makes  the  inter- 
nal incision  just  where  we  want  it,  and  it  is  left  in  position  until 
the  gorget  is  fixed  in  the  staff,  the  point  of  the  blade  being 
grooved  for  the  sliding  down  of  the  point  in  the  gorget.  This  does 
away  with  the  necessity  of  the  external  incision  with  the  knife, 
which  is  one  of  the  most  troublesome  steps  in  the  old  plan  of  ope- 
rating. If  the  urethrotome  does  not  make  a  large  enough  incision 
for  the  gorget,  it  can  be  easily  enlarged  with  a  probe-pointed  bis- 
toury. These  instruments  are  better  than  Prof.  Post's  (of  New 
York)  arrow-pointed  lithotome,  for  this  reason  :  the  staff  does  not 
have  to  be  taken  out  and  another  guide  put  in. 

REPORT   OF   CASES. 

Operation  with  Listruments  of  the  Author  s  Invention — ]\Ir. 

,  of  Liberty  county,  Texas,   applied  to  me  for  treatment  in 

18 — .  He  had,  for  some  months  previous,  experienced  much  diffi- 
culty in  urinating ;  and  on  one  occasion,  the  difficulty  being  so 
great,  the  itching,  burning  sensation  so  disagreeable,  he  pulled  a 
small,  green  vine,  and  introduced  a  foot  of  it  into  the  urethra  with 
hope  of  obtaining  relief.  From  this  time  he  grew  rapidly  worse  ; 
micturition  and  defecation  were  attended  with  violent,  spasmodic 
straining,  often  passing  blood  from  the  urethra.     Had  been  under 


NEW  SURGICAL  INSTRUMENTS.  149 

the  treatment  of  several  physicians,  who  gave  him  various  medi- 
cines but  no  relief.  One  had  made  a  careful  examination  and  pro- 
nounced his  suffering  due  to  stone  in  the  bladder,  and  attempted 
its  removal  by  crushing,  but  failed. 

I  introduced  the  sound,  and  without  difficulty  detected  a  stone. 
After  withdrawing  the  sound  he  suffered  much,  and  passed  a  small 
quantity  of  urine,  pus  and  mucus.  His  condition  was  unfavorable 
for  an  operation,  being  then  anaemic  and  the  subject  of  malarial 
cachexia,  with  harassing  cough.  After  a  full  statement  of  his 
situation  and  chances  of  recovery — which  were  most  doubt- 
ful— ^he  decided  to  have  the  operation  performed.  He  was  placed 
upon  suitable  preparatory  treatment,  and  the  operation  deferred 
one  week. 

Operation. — Having  the  students  present  and  the  patient  chloro- 
formed, the  bilateral  section  was  made  with  the  instruments  shown  in 
Figs.  43,  44.  As  can  be  seen,  they  are  almost  self-acting,  and  with 
them  the  operation  can  be  made  as  safely  with  the  surgeon's  eyes 
blindfolded  as  he  can  with  the  ordinary  instruments  when  his  eyes 
are  open.  All  the  skill  required  is  to  know  where  the  bulb  of  the 
urethra  is,  and  how  to  introduce  this  staff.  As  will  be  seen,  the 
curve  of  the  staff  and  urethrotome  is  the  same  as  that  used  by 
Prof.  N.  B.  Smith,  of  Baltimore,  with  the  exception  of  a  fenes- 
trated groove  instead  of  his  hollow  groove  and  cup  for  the  bistoury. 
The  staff  is  grooved  at  the  point  where  the  urethrotome  cuts  into 
the  urethra,  and  on  the  back  of  the  blade  of  the  urethrotome  is  a 
groove,  into  which  the  knob  on  the  end  of  the  gorget  passes  in  its 
way  to  the  fenestrated  groove  in  the  staff.  Having  once  introduced 
the  gorget  into  the  groove,  it  is  impossible  for  it  to  slip  out,  or  turn 
to  the  right  or  left ;  therefore,  there  is  no  danger  of  cutting  the 
rectum  or  pubic  artery,  unless  it  is  abnormal  in  its  course.  Hav- 
ing made  the  incisions  the  gorget  is  pulled  back  to  the  point  of 
entrance,  and  Avithdrawn  with  care  and  safety. 

The  stone  being  of  the  phosphatic  variety,  crushed  in  attempting 
to  remove  it,  consequently,  had  to  be  taken  out  in  fragments. 
There  was  but  little  hemorrhage,  the  patient  reacted  well  and 
quickly,  as  it  took  but  a  few  minutes  to  complete  the  operation. 
The  following  night  he  was  taken  with  a  chill ;  double  pneumonia 
followed,  and  he  died  on  the  eighth  day  after  the  operation. 

A  post-mortem  exhibited  a  large  abscess  on  both  sides  of  the 
prostate.     The  one  on  the  right  was  packed  with  minute  particles 


150  OEIGINAL    CONTEIBUTIOXS   TO    OrERATIVE   SUEGERY. 

of  stone ;  the  incision  passed  througb.  the  one  on  the  left.  The 
bladder  was  found  much  contracted  and  in  folds;  entirely  denuded 
of  its  mucous  coat  in  places,  with  the  muscular  coat  very  dark, 
almost  black.  The  lungs  were  not  examined,  as  all  present  were 
agreed  that  he  died  of  pneumonia.  However,  the  condition  of  the 
prostate  and  bladder  were  sufficient  to  have  caused  death. 

From  an  experience  of  twenty-three  years  in  the  practice  of 
surgery,  it  is  believed  that  facts  will  warrant  me  in  saying  that 
urinary  calculi  are  of  rare  occurrence  in  Texas ;  owing  in  part,  no 
doubt,  to  the  general  use  of  cistern  water.  During  the  practice  of 
a  number  of  years  in  the  counties  of  Brazoria  and  Gonzales,  when 
there  were  but  few  cisterns,  no  cases  of  stone  in  the  bladder  were 
seen,  but  treated  three  old  men,  natives  of  Kentucky  and  Tennes- 
see, for  gravel ;  one  of  whom  died  from  infiltration  of  the  perineum. 
The  second  recovered  entirely  by  the  use  of  twenty  grains  of 
bitartrate  of  potassium,  three  times  daily,  in  conjunction  with  a 
liberal  quantity  of  onions,  lettuce,  parsley  and  carrots,  as  articles 
of  food.  These  vegetables,  it  is  thought,  exert,  to  a  limited  extent, 
a  dissolving  influence  on  urinary  calculi.  Case  third  was  often 
relieved  from  attacks  of  gravel  with  the  bitartrate  of  potassium 
and  anodynes,  but  finally  died,  as  did  the  first  case,  with  infiltra- 
tion. 

Mr.  P.,  a  native  of  Tennessee,  applied  to  me  in  1858  for  the  re- 
moval of  a  calculus  of  the  oxalic  variety,  which  had  lodged  within 
the  glans  penis.  He  had,  for  several  years,  suffered  with  symp- 
toms of  gravel.  The  penis  was  much  swollen  and  painful ;  had 
made  an  attempt  to  remove  it  himself.  After  putting  him  under 
the  influence  of  chloroform,  an  unsuccessful  attempt  was  made  to 
extract  it  with  a  pair  of  forceps.  A  scooped-end  probe  was  then 
passed  down  under  and  behind  the  stone ;  with  some  manipulation 
and  difficulty  its  removal  was  finally  accomplished. 

In  1863,  Mr.  H.,  a  German  by  birth,  aged  eighteen  years,  was 
brought  to  mo  by  the  late  Dr. ,  of  this  city.  Upon  examina- 
tion it  was  ascertained  that  this  young  man  had  a  small  stone  lodged 
in  the  urethra,  just  anterior  to  the  scrotum.  Ansesthesia  having 
•  been  induced,  a  small  scooped-end  probe — as  in  the  case  above 
stated — was  passed  beneath  and  behind  the  stone,  and  its  removal 
accomplished  without  difficulty. 

Surgeon  Fisher  brought  me,  in  1864,  a  boy  aged  fourteen  years, 
a  native  of  Houston,  who  had  been  afflicted  with  stone  for  four  or 


NEW  SUEGICAL   INSTRUMENTS.  151 

five  years.  His  general  health  was  very  mucli  impaired ;  was  the 
subject  of  chills,  fevers,  dropsy  and  prolapsus  ani.  After  restoring 
his  health  in  part,  with  appropriate  treatment,  an  operation  was 
decided  on.  Suitable  instruments  could  not  be  obtained — it  was 
during  the  late  war — therefore,  recourse  was  had  to  a  sound  of  the 
old  staff  style,  a  straight  bistoury  and  forceps.  Assisted  by  Sur- 
geon Fisher,  assistant  Surgeons  Eugely  and  Francis,  the  patient 
being  chloroformed,  the  lateral  incision  was  made,  and  a  stone  the 
size  of  a  filbert,  extracted.  While  making  the  incision  in  this  case, 
and  just  as  the  prostatic  plunge  was  made,  the  rectum  was  forced 
down  by  the  sphincter  and  severely  cut.  This  accident  was 
a  source  of  much  annoyance,  and  greatly  retarded  the  patient's 
recovery.  Fecal  matter  passed  for  several  weeks  through  the 
urethra ;  every  effort  to  produce  union  was  futile,  until  the  septum 
was  cut  into  the  rectum — as  in  fistula  in  ano — after  which  the  pa- 
tient gradually  recovered. 

Cutting  the  rectum  in  the  case  above  reported,  suggested  the 
modification  of  Dr.  Goodwin's  fenestrated  staff  to  that  of  Dr. 
Smith's.  The  curvature  in  the  staff  of  the  former  was  insufficient 
to  prevent  pressure  on  the  rectum,  and  his  gorget  was  bent  at  the 
blade,  almost  to  an  acute  angle.  When  the  author's  staff  is  intro- 
duced, it  produces  no  more  pressure  than  an  ordinary  catheter,  the 
urethral  part  of  which  can,  if  too  large,  be  replaced  by  a  smaller 
one ;  the  urethrotome  answering  for  any  sized  staff.  His  gorget  is 
curved  at  the  handle,  the  blades  are  movable,  and  larger  or  smaller 
ones  can  be  put  in.  With  it  can  be  made  the  lateral,  bilateral  and 
median  incisions.  In  all  cases  of  perineal  lithotomy,  these  instru- 
ments are  undoubtedly  the  safest  and  best. 

In  1865,  I  removed  a  stone  the  size  of  an  almond,  from  a  negro 
girl  aged  nine  years,  a  native  of  Colorado  county,  Texas,  In  this 
case  the  incision  was  made  on  a  grooved  director,  the  sphincter 
divided  sufficiently  with  a  little  dilatation  to  admit  the  forceps  and 
remove  the  calculi.     She  recovered  and  remains  well. 

A  messenger  summoned  me  quite  hurriedly  one  morning  in  1868, 
in  Galveston,  to  see  a  child  aged  fourteen  months,  who,  as  he  said, 
had  retention  of  urine  with  convulsions.  The  little  fellow  was 
found  in  great  agony — penis  swollen  out  of  all  proportion.  In  try- 
ing to  introduce  a  No.  4  child's  catheter,  a  stone,  the  size  of  an 
English  pea,  was  discovered  three-fourths  of  an  inch  from  the 
meatus.     Having  no  scoop  or  forceps  present  that  could  be  used,  a 


152         ORIGINAL   CONTRIBUTIONS   TO  OPERATIVE   SURGERY. 

hair-pin  was  inserted  under  and  behind  the  stone.  "With  this  im- 
provision  it  was  extracted  very  readily. 

Mrs.  A.,  aged  forty  (negress),  came  to  me  from  Grimes  county, 
in  March,  1870.  She  said  she  had  been  afflicted  for  months  with 
almost  constant  vomiting,  soreness  of  the  bladder,  and  that  her 
urine  deposited  a  quantity  of  sediment  resembling  brick  dust  in 
color.  I  sounded  her,  and  detected  a  rough,  grating  surface  within 
the  bladder.  Upon  withdrawing  the  sound  she  passed,  with  much 
difficulty  and  pain,  a  small  amount  of  urine,  which,  when  exam- 
ined, was  found  to  contain  a  quantity  of  minute  particles  of  calculi. 
The  patient  being  in  good  condition,  an  operation  was  determined 
for  the  following  evenina;. 

Operation. — In  the  presence  of  the  students,  and  assisted  by  the 
professors  of  the  Galveston  Medical  College,  the  patient  chloro- 
formed, a  catheter  inserted  in  the  urethra,  and  the  vagina  dilated 
with  Sims'  speculum,  a  straight  incision — large  enough  to  admit 
the  forceps — was  made  through  the  vesico-vaginal  septum,  and 
three  drachms  of  soft  particles  of  calculi,  much  resembling  elate- 
rium,  were  removed.  The  bladder  was  then  thoroughly  washed 
out  with  a  Davidson's  syringe,  and  the  finger  introduced,  but  find- 
ing no  particles  remaining  the  incision  was  closed  with  Sims'  suture 
for  vesico-vaginal  fistula.  On  the  eighth  day  the  ligatures  were 
removed  and  the  patient  put  on  ten  drops  of  nitro-muriatic  acid  in 
a  glass  of  water,  three  times  daily.  She  was  discharged,  well,  on 
the  20th  of  April  following. 

The  particles  of  calculi  in  the  case  above  reported  were  analyzed 
by  Prof.  Goodwin,  who  pronounced  it  phosphate  of  lime  and  soda. 
Last  summer  I  was  informed  that  this  patient  was  suffering  again 
with  the  symptoms  she  had  prior  to  the  operation.  She  was  placed 
on  the  acid  treatment  again,  and  her  family  requested  to  notify  me 
if  she  did  not  improve  ;  as  yet,  have  heard  nothing  further  from  her. 

Strictores  of  the  Urethra. 

To  fully  comprehend  the  nature  of  the  urethra,  it  will  be  well  to 
premise  with  the  surgical  anatomy  of  the  urethra.  The  urethra, 
in  its  natural  and  healthy  condition,  is  from  five  to  seven  inches  in 
length,  and  is  an  irregular  tube  with  longitudinal  folds,  and  formed 
by  muscular  fibres;  there  are  no  transverse  folds  in  its  natural 
state,  but  it  contracts  by  its  own  resiliency.  The  penis  is  composed 
of  the  urethral  canal  and  the  corpus  spongiosum,  corpora  cavernosa, 


NEW   SUEGICAL   INSTEUME]SfTS.  153 

and  the  glans  penis,  with  skin  and  cellular  tissue.  The  gland  is 
the  least  resilient,  and  causes  a  contraction  in  the  urethra  where  it 
joins  with  the  corpus  spongiosum.  The  urethral  canal  then  en- 
larges and  forms  a  striated  structure  ;  the  membranous  portion  is 
but  a  continuation  of  the  corpus  spongiosum,  where  there  is  a  slight 
sinus,  and  an  enlargement  from  the  former  portions  of  the  canal  in 
the  proportion  of  three  to  five  inches,  forming  what  is  called  the 
membranous  portion  of  the  urethra,  which  terminates  at  the  pros- 
tate gland,  forming  the  prostatic  portion.  Strictures  occur  in  these 
positions  according  to  the  following  table  : — 

Glandular  portion 17  per  cent. 

Gland  to  bulb 16        " 

Membranous  portion Q7        " 

Prostatic  stricture  very  rarely,  if  ever,  occurs ;  perhaps  only  by 
an  enlargement  of  the  gland. 

The  causes  of  stricture  are  various,  but  all  originate  from  inflam- 
mation of  the  mucous  coat  of  the  urethral  canal,  common  or  specific 
causes,  as  the  inflammations  produced  by  cantharides,  turpentine, 
gin,  etc.;  also  from  the  passage  of  calculi,  injuries  from  bougies, 
bruises  and  contusions,  specifics,  as  syphilis,  gonorrhoea  and  gleet. 

Symptoms  of  Stricture. — A  slight  obstruction  to  the  full  flow  of 
urine  is  almost  the  first  symptom  of  stricture.  A  frequent  desire 
to  urinate,  stream  forked,  twisted,  and  at  times  entirely  obstructed ; 
urine  drops  away  without  any  stream ;  bladder  rarely  emptied ; 
pus  and  mucus  drip  away  after  urination ;  urine  unusually  ammo- 
niacal,  and  has  a  whitish,  sticky  sediment ;  patient's  general  health 
bad,  and  spirits  deprassed. 

Strictures  may  be  years  forming,  or  they  may  occur  in  a  few 
hours ;  the  stream  may  be  only  slightly  checked,  or  entirely  sup- 
pressed. Stricture  may  form  in  various  parts  of  the  same  patient. 
From  one  to  seven  strictures  have  been  found  in  the  same  patient. 
They  may  be  longitudinal,  or  formed  by  a  simple  band,  produced, 
in  both  instances,  by  deposition  of  coagulable  lymph  beneath  the 
mucous  membrane. 

Stricture  may  be  permeable  or  impermeable — spasmodic,  remit- 
tent, or  permanent — incon tractile. 

Strictures  from  contusions  and  wounds  are  liable  to  produce 

fistulse  in  the  perineum,  spadise,  or  hyperspadise,  and  sometimes  the 

urethra  is  closed  so  as  not  to  admit  the  passage  of  a  bougie.     I 

consider  those  strictures  that  a  No.  1  catheter  cannot  pass  to  be 

11 


154         OEIGINAL   CONTEIBUnOTTS   TO  OPERATIVE  SUEGERT. 

impermeable,  not  meaning  by  that  phrase  that  no  urine  passes 
along  the  urethra,  for  there  are  tortuous  canals  or  cribriform 
openings  in  the  membranous  portion  of  the  urethra  that  will  per- 
mit the  passage  of  urine,  but  will  not  admit  the  passage  of  a 
bougie,  or  at  least  I  have  met  several  in  which  I  could  not  pass  a 
bougie  or  a  sound. 

Sounding  for  Stricture. — This  is  a  delicate  surgical  operation, 
and  requires  experience  and  skill.  The  rules  are  simple  and  plain, 
but  it  requires  an  educated  hand  to  perform  it  well.  The  best  instru- 
ment is  a  curved  one,  either  silver,  lead  or  steel,  and  curved  about 
one  inch  from  the  point.  No.  8  is,  perhaps,  the  best,  and  should  be 
inserted  without  force,  beginning  with  the  curve  pressed  up  under 
the  pubis,  gently  pressed  along;  and  if  it  will  not  pass  in  this 
position,  the  curve  shoidd  he  turned  first  to  the  right  and  then  to 
the  left,  and  finally  downward.  If  there  is  an  opening  in  any 
side,  this  examination  will  find  it,  and  the  point  will  enter.  If  a 
No.  8  is  too  large,  take  a  smaller  size,  say  No.  1,  and  use  it  in  the 
same  way.  In  nearly  every  instance,  if  the  opening  will  admit 
the  point,  it  can  be  passed.  There  are  frequently  several  passages 
to  the  bladder,  and  the  sound  may  pass  through  one  and  afterward 
through  the  other.  If  it  pass  toward  the  rectum,  the  sound  will 
be  more  easily  felt  through  the  rectum,  and  will  appear  to  be  out 
of  the  urethral  canal,  which  is  the  fact ;  the  canal  being  closed  or 
obstructed  will  form  a  passage  below. 

It  is  thought  not  to  be  necessary  to  understand  the  anatomy  of 
the  parts  to  pass  a  bougie.  This,  I  grant,  with  a  flexible  instru- 
ment, is  not  absolutely  necessary,  but  with  a  sohd  instrument,  and 
not  flexible,  I  think  it  very  dangerous;  and  if  the  least  force  is 
used,  a  false  passage  will  be  formed.  In  using  the  catheter  or 
sound  I  have  found  it  more  satisfactory  if  my  patient  was  under 
chloroform,  but  to  one  not  well  acquainted  with  the  anatomy  of  the 
parts,  I  would  not  advise  this,  for  fear  too  much  force  might  be 
used.  If  the  curve  of  the  instrument  is  kept  well  under  the  pubis 
no  serious  danger  is  liable  to  occur,  but  should  it  be  turned  to  the 
right  or  left,  and  especially  downward,  there  would  be  formed,  in 
all  probability,  a  false  passage,  and  perineal  infiltration,  gangrene 
and  fistulge  as  the  result. 

If  the  patient  is  very  nervous,  and  there  is  much  hemorrhage,  it 
is  best  to  apply  local  applications  to  the  urethra  and  antiphlogistic 
remedies  for  a  few  days,  then  try  again. 


NEW  SUEGICAL   INSTRUMENTS.  155 

The  endoscope  is  a  good  instrument  in  diagnosing  strictures  of 
tlie  annular  kind,  and  they  can  be  well  seen,  as  shown  in  the  case 
of  Eno-ineer  Stone,  but  is  more  useful  in  the  examination  when 
the  stricture  is  forming,  than  when  it  has  formed.  By  its  use  we 
soon  stop  the  inflammation,  by  direct  application  of  nitrate  of 
silver  to  the  part  inflamed,  thus  preventing  the  effusion  of  coagu- 
lable  lymph  that  makes  the  stricture. 

The  instrument  should  be  well  oiled  before  using,  and  if  the  canal 
is  small,  and  the  instrument  fits  tight,  it  would  be  well  to  inject 
the  urethra  with  a  drachm  of  sweet  oil  before  using  the  bougie. 

Bougies. — The  silver  bulb  sound  is  an  excellent  instrument,  but  I 
prefer  the  lead  bougies,  that  I  can  bend  to  any  angle,  to  all  others  ; 
and  the  lead,  I  believe,  is  useful  in  the  cure  of  any  acute  inflammation 
that  may  exist.  They  are  sufficiently  firm  to  bear  any  amount  of 
pressure  that  ought  to  be  used,  when  we  use  above  No.  9,  French 
scale.  The  French  scale  is  the  best,  and  all  manufacturers  should 
use  it.  We  have  now  great  confusion,  every  instrument  maker 
having  his  own.  We  shall  use  this  scale  entirely,  see  Fig.  51, 
page  165.  The  lead  bougies  will  not  break  easily,  and  from  four  to 
twelve  are  large  and  small  enough ;  these  may  be  graduated  to  any 
size,  but  six  is  amply  sufficient.  When  you  have  put  in  a  No,  4, 
and  let  it  stay  two  hours,  or  even  half  an  hour,  you  can,  on  taking 
it  out,  insert  No.  6,  and  so  on. 

When  inserted  it  should  be  left  in  place  for  a  few  hours,  and  if  a 
catheter,  may  be  kept  in  for  twelve.  After  that  time  I  think  it  best 
to  give  the  urethra  rest,  as  there  will  be  more  or  less  pain  in  the 
bladder.  I  tie  the  catheter  to  the  testicles  with  a  tape,  and  this 
does  not  prevent  the  patient  from  moving,  and  I  have  never  found 
any  inconvenience.  Putting  an  adhesive  strip  to  the  penis  or  a 
bandage  around  the  body  is  entirely  unnecessary,  and  I  am  really 
surprised  that  surgeons  ever  recommended  it;  but  I  find  the  great 
Malgaigne  has  devoted  several  pages  to  the  difierent  modes  of  con- 
fining the  catheter  in  the  male  urethra.  I  have  never  resorted  to 
any  other  mode  than  tying  the  catheter  down  to  the  testicles  with 
tape  through  the  two  eyes  of  the  ordinary  catheter,  and  when  I 
have  used  bougies,  I  have  put  eyes  to  them  or  bent  lead  eyes  into 
the  loop  or  hole  in  the  top,  through  which  I  passed  the  tape  and 
around  the  sides  of  the  penis  to  the  base  of  the  testicles,  where  it 
was  tied  lightly,  but  not  loose  enough  for  either  testicle  to  pass 
through  the  loop. 


156 


ORIGINAL   CONTEIBUTIONS   TO   OPERATIVE   SUEGERY. 


Treatment  of  Stricture. — Eesilient  or  spasmodic  stricture  may 
be  cured  by  internal  remedies  and  tbe  warm  bath,  but  it  often 
becomes  necessary  to  pass  a  catheter  to  remove  the  urine,  which  is 
irritating  and  increases  the  symptoms.  Cold,  venereal  excess, 
morphine  and  various  other  causes  produce  spasmodic  strictures 

without  venereal  taint.  Warm 
fomentations  to  the  perineum, 
warm  bath,  and  the  moving  of 
the  bowels  with  cream  of  tar- 
tar, citrate  of  magnesia  solu- 
tion, or  any  mercurial,  will 
often  effect  a  cure,  or  at  least 
give  immediate  relief;  but 
these  are  liable  to  return,  and 
w^hen  it  occurs  I  usually  oper- 
ate by  internal  incision  with  a 
common  urethrotome,  as  shown 
in  Westmoreland's,  Fig.  45,  1. 
I  have  used  internal  urethro- 
tomy, cutting  through  the  mus- 
cular coats  with  the  urethro- 
tome while  they  are  contracted, 
and  then  inserting  a  No.  27 
catheter,  tying  it  in  until  the 
urine  begins  to  run  along  its  . 
line,  when  it  is  removed,  rein- 
serting it  each  day  for  several 
hours,  and  continuing  its  use 
once  a  day  for  eight  days,  and 
once  a  week  for  several  weeks. 
This  has  proved  entirely  suc- 
cessful in  cases  where  I  have 
followed  this  plan.  When  I 
have  been  able  to  pass  the 
stilet  into  the  bladder,  I  have  invariably  used — as  the  attached 
report  of  cases  will  show — internal  urethrotomy  with  entire  suc- 
cess. But  when  no  sound  can  be  passed,  I  have  used  external 
incision  upon  a  common  grooved  director  (Fig.  45,  4),  or  a  Sims' 
sound  (Fig.  45,  3),  passed  as  far  as  I  possibly  could,  cutting  down 
directly  over  it  and  through  the  stricture  with  the  bistoury  (Fig. 


NEW   SURGICAL   INSTRUMENTS. 


157 


45,  5),  and  then  passing  tiie  sound  further  on,  until  I  reached 
another  stricture,  or  into  the  bladder,  hooking  up  with  a  tenacu- 
lum (Fig.  46,  5),  all  hard  or  indurated  tissue,  and  cutting  it  out 
at  various  times,  not  all  at  once,  for  fear  of  hemorrhage  and  peri- 
neal infiltration,  and  gangrene. 


1.  Catheter,  for  Retention,  old  style.    2.  Filiform  Catheter. 
Catheter.    4.  Grooved  Director.    5.    Tenaculum. 


3.  Filiform.  Bougie  and 
6.  Bistoury. 


For  perineal  fistulse  there  is  no  remedy  but  to  cut  down  on  the 
urethra,  and  open  up  all  the  fistulous  canals,  excising  all  the  hard- 
ened, indurated  parts,  letting  them  fill  up  by  granulations,  which 
has  proved  successful  in  all  my  cases,  the  patients  enjojTing  perfect 
health,  who  were  a  nuisance  to  themselves  and  all  about  them  before 
the  operation  was  performed. 


INTERNAL   INCISION. 

Engineer ,  of  Eevenue  Cutter  Delaware,  applied  to  me  in 

1866,  for  treatment  of  a  stricture  at  the  bulbous  portion  of  the 


158         OEIGnTAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 

urethra,  of  several  years'  standing.  He  had  tried  dilatation  with 
only  partial  success,  and  it  had  returned  in  March,  1866,  much 
worse  than  ever.  Upon  sounding  him  I  found  that  a  No.  27  passed' 
to  the  bulbous  portion  of  the  urethra,  about  four  inches  from  the 
meatus.  I  succeeded  in  passing  a  No.  5,  which  admitted  the 
director  of  the  urethrotome  I  used,  which  is  made  the  size  of  a 
No.  21,  with  a  central  staff  passing  through  the  catheter  with  a  slight 
enlargement  at  the  end  (Fig.  45, 1).  This  is  made  to  protrude  about 
three  inches  beyond  the  catheter.  In  this  same  catheter  is  a  convex 
blade  moved  by  a  staff,  also  running  on  the  former  staff  and  fixed 
to  a  button,  by  which  it  is  moved.  These  are  drawn  within  the 
catheter,  and  it  inserted  to  the  stricture;  then  the  director  passed 
through  the  stricture  into  the  bladder;  after  which  the  bladed 
staff  is  pushed  through  the  stricture,  cutting  its  folds.  After  ex- 
amining this  patient  with  the  endoscope,  he  consented  I  should 
operate,  which  I  did  in  the  presence  of  and  assisted  by  Dr.  Mintzer 
and  Medical  Director  Taylor. 

The  patient  being  on  his  back  and  under  chloroform,  I  inserted 
the  catheter,  with  staffs  drawn  up,  then  passed  the  director  into 
the  bladder  and  cut  the  stricture  through  and  through  with  the 
convex-bladed  staff;  after  which  I  pulled  up  the  two  staffs  and 
passed  the  catheter  into  the  bladder.  Then  removing  the  same,  I 
inserted  a  No.  30  catheter  and  tied  it  in  as  above,  passing  tape 
through  its  eyes  and  down  the.  penis  around  the  testicles,  and  then 
tying  it,  put  a  stopper  into  the  orifice  and  left  him  in  bed  ten  days. 
The  catheter  was  removed  daily,  cleansed  and  reinserted.  Patient 
was  not  allowed  to  urinate  without  the  catheter  being  in  place, 
for  eight  days.  There  was  only  slight  hemorrhage  and  no  bad 
symptoms.  Patient  continued  to  pass  mucus,  and  had  to  insert 
catheter  occasionally  for  nearly  a  year.  The  upper  portion  of 
stricture  remained  and  could  be  seen  through  the  endoscope,  and 
produced  a  burning  sensation  when  patient  used  the  catheter. 
The  stream  was  full  and  free,  and  the  patient  never  suffered  from 
retention  of  urine  afterward. 

Case  2. — Mr.  T.  K.  N.,  aged  thirty-six,  of  Brazoria  county,  ap- 
plied to  me  in  September,  1866.  This  was  a  longitudinal  stricture 
with  three  contracted  heads,  of  fifteen  years'  standing.  Had  suf- 
fered much  and  often  had  to  resort  to  the  catheter,  especially  after 
taking  cold,  or  any  irritating  drinks.  I  used  the  same  instrument 
on  this  as  on  case  No.  1,  but  there  was  excessive  hemorrhage  and 


NEW   SUEGICAL   IXSTEUMENTS. 


159 


mucli  pain,  which  was  subdued  by  opiates,  and  cold  cloths  to  the 
perineum.  The  catheter  had  to  be  removed  several  times  and  re- 
inserted, but  the  patient  continued  to  improve,  and  in  three  weeks 
was  well  enough  to  return  home ;  is  in  fine  health.  I  operated 
three  times  in  the  Island  City  Hospital,  after  this  plan,  with  entire 
success.  I  do  not  remember  any  peculiar  symptoms,  and  no  bad 
ones,  developing  themselves.     (See  Table  of  Cases,  page  166.) 

holt's  insteume^ts. 
Where  the  urethrotome  does  not  make  an        ,      f^g.  47, 

12  3 

opening  in  the  urethra  large  enough  for  rny 
retention  catheter,  after  incising  with  the 
urethrotome  I  insert  Holt's  dilator  (Fig.  47, 
3),  which  is  the  best  of  any  I  have  seen,  and, 
as  I  think,  a  perfect  instrument;  perfectly  safe 
without  the  urethrotome,  provided  it  can  be 
inserted  into  the  bladder  before  putting  in  the 
dilators.  But  I  have  met  with  many  cases 
in  which  I  could  not  insert  it,  but  could  pass 
the  sound  on  the  end  of  "Westmoreland's  ureth- 
rotome, and  when  even  this  cannot  be  done, 
we  may  pass  the  filiform  bougie  (Fig.  46,  2, 
3,  page  157).  But  when  these  become  neces- 
sary it  is  far  better  and  safer  to  perform  ex- 
ternal incision,  if  the  operator  knows  what  he 
is  about.  No  one  should  attempt  it  unless  he 
is  a  good  anatomist.  The  retention  catheter 
is  indispensable,  whether  you  ineise  or  rupture, 
to  prevent  infiltration  or  contraction,  and  even 
pain,  after  urethrotomy. 

STEICTUEE   WITH   FISTULA    PEEINEI  —  EXTEE- 
NAL   INCISIONS. 

George  Smith,  aged  twenty-five,  nativity 
United  States,  was  operated  upon  for  stricture 
of  the  urethra,  November  19th,  1867 ;  stric- 
ture at  bulb  of  the  urethra;  swellings  from 
contusions  numerous;  the  wound  healed  by 
December  18th  ;  patient  is  considered  well. 

I  proposed  to  lay  the  parts  open  at  once,  upon  his  admission  to 


Holt's  Instruments, 
Improved. 


160         OEIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 

hospital,  but  to  this  he  did  not  consent,  yet  on  the  19th  of  Novem- 
ber he  consented  to  my  cutting  down  on  a  probe  and  opening  the 
two  fistulse,  which  were  well  formed  by  this  time.  I  could  not  pass 
any  sound ;  the  urethra  was  impervious  to  all  sizes. 

Operation. — Patient  being  under  chloroform,  and  assisted  by  Dr. 
Wilkerson  and  the  medical  students,  I  put  down  to  the  first  stric- 
ture an  ordinary  grooved  director  for  hernia,  and  cut  through  to 
its  point,  then  took  it  out  and  passed  along  the  line  of  stricture 
and  under  it,  and  cut  through  the  stricture ;  took  a  No.  21  bougie, 
and  passed  it  on  to  the  second  stricture  beyond  the  testicles,  where 
I  turned  it  out  and  cut  down  on  its  point.  I  then  took  the  grooved 
director  and  inserted  it  from  the  fistulse  toward  the  testicles  and 
between  and  under  them,  cutting  all  the  indurated  portion  with  a 
probe-pointed  bistoury  (Fig.  48).     I  then  took  out  the  sound,  and 


Bistoury  for  External  Incision  of  Strictures. 

passed  a  No.  30  catheter  into  the  bladder,  and  tied  it  in,  as  in  pre- 
vious cases.  Every  few  days  I  would  hook  up,  with  a  tenaculum, 
the  indurated  portions,  and  cut  them  out,  until  I  had  removed  them 
all.  The  parts  healed  up  by  granulation.  Patient  was  discharged 
on  the  18th  of  December. 

James  Kelley,  aged  twenty-five.  I  copy  the  following  from  Hos- 
pital Pvegister : —  • 

James  Kelley,  admitted  Februrary  11th,  nativity  New  York, 
was  operated  upon  for  stricture.  Urethral  incision  one  inch  ante- 
rior to  the  scrotum,  stricture  laid  open,  catheter  passed  through 
two  complete  strictures  into  the  bladder ;  four  fistulse  anterior  to 
the  scrotum,  two  of  them  in  glans  penis.     Discharged  April  22d. 

These  notes  were  made  by  House  Surgeon  Wilkerson,  and  give 
the  dates  and  the  locations  of  the  strictures.  This  was  the  worst 
case  I  have  seen.  The  gland,  as  above  stated,  had  two  fistulse  in 
it,  and  the  external  meatus  would  not  admit  a  probe.  I  first  took 
a  straight-pointed  bistoury,  and  opened  the  gland,  above  where  the 
urethra  ought  to  be,  to  the  first  opening  or  fistula,  and  then  cut 
them  all  into  one.  I  then  took  a  No.  26  catheter  and  inserted  it 
to  the  third  fistula  and  second  stricture,  cutting  it  open  and  down 
so  I  could  pass  it  to  the  fourth,  and  from  it  to  the  bladder.     Con- 


NEW  SURGICAL   INSTRUMENTS. 


161 


Fig.  49. 


tinned  to  cut  out  indurated  portions  for  a  month,  and  healed  up  all 
the  fistula,  except  one  just  in  front  of  the  testicles,  which  was  not 
entirely  closed  when  patient  left.  Same  patient  returned,  looking 
well.  Had  had  the  yellow  fever  the  summer  before,  been  on  the 
city  police,  and  at  work  since  he  left  the  hospital.  Still  small 
opening,  through  which  a  drop  or  two  of  urine  passed,  and  matter 
forming  pus.  Touched  the  opening 
with  a  hot  wire ;  did  not  close  from 
its  cautery,  but  was  finally  closed  by 
a  plastic  stitch-^cutting  out  the  mu- 
cous surface,  and  stitching  it  up  with 
silver  wire.  I  operated  on  two  other 
cases  with  fistulse  after  the  above 
plan,  with  entire  success. 

Edward  Murphy,  aged  twenty- 
seven,  nativity  Ireland,  was  operated 
upon  for  stricture  of  the  urethra. 
Admitted  March  1st  and  discharged 
July  11  th.  Wounds  healed  by  first 
intention. 

Henry  Foster,  aged  twenty-six, 
nativity  Texas,  was  operated  upon 
for  stricture  in  urethra.  Admitted 
June  5th,  and  discharged  August 
14th. 

Remarks. — I  have  not  said  any- 
thing of  dilatation,  for  I  have  almost 
abandoned  this  form  of  treatment, 
because,  in  the  first  place,  it  is  more 
tedious  and  painful;  secondly,  it  is 
more  uncertain,  leaving  a  mucous 
epithelial  discharge — is  always  liable 
to  return. 

I  have  not  used  the  urethrotome- 
cache  of  some  authors  —  because 
where  it  can  be  passed,  the  other 
kind  I  use  is  more  easily  inserted,  and  will  cut  either  backward  or 
forward,  and  is  better  suited  to  every  case.  I  believe  all  strictures 
are  curable,  and  without  danger,  if  treated  prudently  and  skillfully. 
I  do  not  think  external  incision  ever  necessary  when  the  No.  1  size 


Various  Forms  of  Urethrotomes.  A, 
B,  C,  D  cut  upward.  E  cuts  down- 
ward. B  used  iu  the  Meatus,  bulb- 
ous portion. 


162  OEIGINAL   CONTEIBUTIONS   TO   OPEEATIVE   SURGERY. 

sound  can  be  passed  into  the  bladder,  preferring  internal  incision. 
When  there  are  several  passages,  then  external  incision  becomes 
necessary,  to  form  them  into  one.  I  do  not  believe  in  the  rupture 
treatment  of  Dr.  Holt,  except  in  resilient  strictures,  and  after  the 
cutting  of  the  strictures  with  the  urethrotome.  It  is  more  danger- 
ous and  tedious  than  iuternal  incision. 

A  Hew  Form  of  Male  Catheter  for  Stricture  of  the  Urethra,  and  a  New 
Method  of  Retaining  it  in  the  Bladder. 

In  1858  I  had  under  treatment  a  bad  case  of  hypospadias  with 
urinary  fistulse ;  one  in  the  raphe  between  the  testicles,  the  other 
in  the  perineum,  posterior  to  the  testicles  (see  report  of  the  case 
in  Galveston  Medical  Journal,  1866).  Finding  it  absolutely 
necessary  to  keep  the  catheter  in  the  urethra,  to  prevent  closure 
after  incision,  I  resorted  to  the  method  of  tying  it  in  by  means  of 
tape  in  the  rings  of  the  catheter,  and  then  around  the  testicles. 
This  I  found  to  be  an  admirable  method,  and  I  have  used  it 
ever  since.  Malgaigne  and  other  surgeons  have  written  pages  on 
the  different  modes  of  retaining  the  catheter  in  the  male,  none  of 
which  are  satisfactory,  and  all  attended  with  danger  of  penetrating 
the  fundus  of  the  bladder  by  pressure,  producing  slough,  as  they 
all  take  their  "point  d'appui"  from  an  immovable  position,  and 
when  attached  to  the  penis  itself,  it  does  not  allow  of  erection 
without  pain  and  distention,  and  the  flow  of  urine  softens  up  the 
attachment,  or  wets  it,  producing  irritation  and  pain.  Finding 
much  annoyance  in  the  dripping  of  the  urine  over  the  testicles,  I 
first  used  a  plug  or  stopper  in  the  orifice  of  the  catheter;  but  as 
the  bladder  filled  with  urine  it  became  painful;  I  then  resorted 
to  a  gum-elastic  tube,  placed  over  the  mouth  of  the  catheter,  and 
leading  into  a  urinal  or  basin.  This  worked  admirably,  and  seemed 
to  fulfill  all  the  indications;  but  finding  a  large  discharge  of 
mucus,  blood,  epithehal  cells,  and  crystals  of  calculi,  I  saw  the 
necessity  for  a  still  further  improvement,  which  is  shown  in  Fig.  50, 
which  answers  all  purposes ;  by  partially  unscrewing  the  stop-cock, 
we  can  let  the  urine  flow  down  the  tube  into  a  urinal  or  basin 
or  by  taking  out  the  stop-cock,  and  screwing  in  the  nozzle  of 
a  syringe,  we  can  completely  wash  out  the  bladder  without  remov- 
ing the  catheter.  I  make  it  an  invariable  rule  to  keep  the  catheter 
thus  tied  in  until  the  urethra  becomes  so  relaxed  as  to  permit  the 
flow  of  urine  along  its  sides,  when  it  is  always  taken  out.     I  deem 


NEW   SUEGICAL   INSTRUMENTS. 


163 


this  of  great  practical  importance  in  treating  all  kinds  of  strictures, 
whetlier  the  stricture  is  broken  down,  as  in  Holt's  method,  or 
incised,  as  in  Pancoast's  and  others,  and  absolutely  necessary  to 
good  results  in  all  cases  of  external  urethrotomy.  I  have  treated, 
in  this  simple  way,  thirty-one  cases  of  external  urethrotomy,  and 
eighty-six  cases  operated  on  by  the  internal  urethrotome,  with 
only  one  death,  and  perfect  cures  in  all  the  others  (see  Table,  page 
169,  No,  7,  and  Texas  State  Medical  Reports,  for  1871).  In  the 
case  of  death  the  man  had  hiccough  when  he  was  first  operated 
on,  and  was  in  a  comatose  condition  from  ursemic  poison,  with 
gangrene  of  the  prepuce  and  the  cellular  tissue  in  the  perineum. 
He  removed  the  catheter  in  his  delirium,  and  the  urethrotome 


Fig,  50. 


New  Eetention  Catheter  for  Stricture  of  the  Urethra,  A.  A  Screw,  and  Nut  for  its 
Insertion.  B.  Discharge  Pipe,  when  the  Screw  is  withdrawn.  C.  Rinsr  of  Tape 
tying  the  Catheter  around  the  Testicle.  D.  Knot  oX  Tape,  E,  Symphisis  Pubis. 
F,  Testicle, 

had  to  be  used  again,  before  his  bladder  could  be  reached  with  the 
catheter,  and  by  leaving  the  catheter  out  one  night,  he  again 
became  comatosed,  and  finally  died.  I  firmly  believe  he  would 
have  recovered  if  the  catheter  had  been  kept  in.  The  same  difii- 
culty  has  occurred  in  several  other  cases,  hence  the  universal 
application  of  the  catheter  in  these  cases.  There  is  a  further 
advantage  in  keeping  the  catheter  in  after  incising  a  stricture; 
your  patient  is  not  so  liable  to  rigors,  and  he  does  not  suflfer 
from  difficult  urination;  is  not  near  so  liable  to  infiltration.  With 
my  present  experience,  I  would  consider  myself  criminal  if  I  did 
not  use  the  catheter  in  all  cases,  in  the  above  manner.  The 
catheter  produces  no  irritation  as  (when  the  bladder  contracts)  it 


164  ORIGIiS^AL   CONTEIBUTIONS   TO    OPERATIVE   SUEGERY. 

moves  up  and  down  as  it  fills  with  urine ;  the  testicles  draw  the 
icatheter  back,  and  it  is  thus  movable  at  all  times,  relieving  tension 
and  irritation.  My  success  in  treating  strictures  requiring  exter- 
nal and  internal  incision  is  greater  than  any  statistics  published, 
and  I  attribute  it  alone  to  the  use  of  the  catheter,  and  the  mode  of 
its  retention. 

EEPOET   OF    CASES. 

In  the  summer  of  1858  a  negro  man,  property'  of  T.  J.  Sweeny, 
of  Brazoria  County,  Texas,  was  sent  to  me  for  treatment  for  peri- 
neal fistula  and  hypospadias  of  the  peni^,  caused  by  a  fall  across 
the  gunwale  of  a  boat.  But  little  urine  was  discharged  through 
the  natural  channel,  but  the  greater  part  passed  out  behind  the 
scrotum,  from  several  orifices.  His  constitution  was  good,  and  the 
injury  was  of  long  standing. 

I  determined  to  relieve  him  by  an  operation,  or  rather,  opera- 
tions. So  I  took  a  common  tenotomy  bistoury  (see  Fig.  46,  6,  page 
157),  and  a  female  catheter ;  I  inserted  the  catheter  in  the  first 
fistula  down  to  the  stricture,  the  cause  of  the  hypospadias,  and  cut 
down  on  the  catheter,  reaching  it  through  the  fistulous  opening.  I 
then  tied  the  catheter  in  by  a  string  through  its  eyes  and  the  open- 
ing in  its  point,  and  let  the  stricture  heal  up  over  the  catheter. 
When  this  was  done,  I  passed  the  catheter  on  to  the  second  hypos- 
padias, and  cut  the  stricture  as  before,  again  tying  in  the  catheter. 
When  this  was  sufficiently  healed  up,  I  took  a  male  catheter,  and 
passed  it  to  the  stricture  beyond  the  scrotum,  and  cut  all  the  fistu- 
lous openings  into  one.  I  then  tied  the  catheter  in,  letting  its  point 
come  out  at  the  fistulous  opening,  and  retaining  the  catheter  in 
this  situation  by  a  piece  of  tape  through  the  eyes  of  the  catheter 
and  through  the  holes  in  its  point.  This  healing  up,  I  then  passed 
the  catheter  into  the  bladder  and  tied  it  in  with  a  tape  in  the  eyes 
and  around  the  scrotum  and  testicle,  as  seen  in  Fig.  50,  page  163, 
the  common  two  rings  used  instead  of  the  one  without  the  screw. 
I  believe  this  was  the  first  efibrt  ever  made  to  tie  a  catheter  in  the 
urethra  or  bladder,  by  fastening  it  around  the  testicles  instead  of 
the  penis,  or  by  belts  around  the  body. 

This  I  claim  an  invention  of  great  value,  and  one  I  have  used 
successfully  ever  since.  See  Galveston  Medical  Journal,  and  Table 
of  Cases,  page  166. 

The  man  took  measles  while  I  was  absent,  and  died  from  flux 


NEW  SURGICAL   INSTRUMENTS.  165 

while  at  this  stage.  In  treating  other  cases,  I  found  that  the 
urine  passing  off  on  the  legs  and  clothes  was  ve^y  annoying.  I, 
in  my  next  case,  stopped  up  the  mouth  of  the  urethra  with  a  plug, 
and  pulled  it  out  when  the  patient  wished  to  urinate.  The  next 
case  I  applied  a  tube  of  india-rubber  to  the  mouth,  and  let  it  run 
out  into  a  basin.  This  acted  well,  and  kept  the  patient  perfectly 
clean;  by  this  means,  and  its  attachment  to  the  scrotum,  I 
could  keep  the  catheter  in  indefinitely,  as  there  was  no  power  to 
press  it  back,  to  produce  lacerations  or  sloughing,  as  occurred  when 
fixed  to  the  body,  and  it  could  not  get  loose  and  come  out,  as  it 
often  did  when  fixed  around,  the  penis ;  it  made  the  retention 
more  simple,  and  prevented  any  dripping  of  urine,  allowing  the 
patient  to  turn  over  on  his  side,  or  to  the  right  or  left. 

The  catheters  are  made  in  sizes  from  fifteen  to  twenty-one  Ame- 
rican scale,  or  twenty- three  to  thirty-two  French  (Fig.  51),  and  after 


Fig.  51. 


>io.  11,  12.  /^a :  ,14  :  15' .  1& 


:24v,  33    :.2.2:.  ..ai     .20:'  >i:a' 


cutting  a  stricture  or  lacerating  it,  this  catheter  is  put  in  (usually 
No.  30)  and  tied  in  with  a  tape  tied  around  the  scrotum  and  in  the 
eye  or  ring  of  the  catheter,  and  kept  in  until  the  urine  burrows  along 
the  catheter,  when  it  is  taken  out  and  inserted  every  night,  and  tied 
in  for  half  an  hour  to  two  hours,  until  the  incision  heals  up  and  the 
stricture  is  absorbed.  When  the  patient  wished  to  urinate,  a  cup 
or  bottle  was  held  under  the  open  tube,  and  the  screw  A  (Fig.  50) 
unscrewed  to  the  mouth  of  the  tube,  when  the  urine  flowed  into  the 
cup  or  bottle  without  wetting  the  bed.  If  it  becomes  necessary  to 
wash  out  the  bladder,  the  screw  is  taken  out  and  the  point  of  a 
syringe  inserted  in  the  screw  end  of  the  catheter,  and  water  is 
pumped  in  and  run  out  at  the  tube  B.  Solutions  of  any  or  all  salts 
were  also  used  when  necessary,  with  no  injury  to  clothing,  using 
my  catheter  instead  of  the  usual  double  cannula,  which  has  some 
advantage,  as  we  have  a  constant  stream,  but  has  the  disadvan- 
tage of  being  inserted  each  time. 


166 


ORIGINAL   CONTRIBUTIONS  TO   OPERATIVE   SURGERY. 


'^  'O  -^  .ii  .o 


13  .,  "-!:3   3     ^^a"? 


a  8    . 

3-3  3  S-f!'?i 


5     !- 


?  s 


;  o  -<5  ,a  '^  t-h" 


o 

(>^ 

•w 

rt 

^_ 

X) 

i 

c3 

p< 

« 

^ 

Ci 

,_^' 

pfl 

o 

>-. 

'  ' 

o 

>', 

,a 

03 

> 

*"* 

3 
u 

6 

o 

o 

T— 1 

;2 

^ 

p. 

cS 

S 

IJS"^ 


8  '3,  Jr  ^ 


Oj   ^    O  ^5 

CO 

CO 

C 

•A   A 

OS    — 

t>  aj 

OS  O 

U   CS 

SCO 

^-a 

^   O 

^   .. 

feSa 

1  S.2 

=f-  -f^    c^ 

<o  ^  h 

s§i 

13 


«  2 

aj'O  CO 
aS^'-i 


-  ^9. 

3  I-      >H  . 

H  4)  a  M 

_^  p.  ^  a 

3  rn     ^  05 

:  o  «  3 

„  q  -^  o 


O   C   ci   o3 


"3  a 


4;  ^ 


"  fl  ^^  "a 

^»   S   S  Ji 

a      a  "^^ 

a  =>  -►^  _- . 

r  r.     O  a     73 

"2   -2  '='  « 

c  '•♦^   U  to  -^ 


111 
o 


o  u 


dj  q  o  ■  •-  a 

o  ^  r^ 

"^  a  0)' 


03  oQ  i; 

b  ^  5 
tpl  3  a 


S 

cc" .. 

a  "^ 

»-5 


3'+-'  i^       a, 

v,  I  a  a  '-' 
;-  I  c  2  c3  _ 
'o  (u  o,a_  a   . 

2  -w  „  a  a  c-'C 

•  !h  o  1-  u  a>  a  .3 

a  „^j=  J  c3^ 


o  -u  a 
a  rt  03 


oS  ®-2 

'a  a  o  "3 

I— I  _0   03  ^ 

.  0)  a  -I 

'^      fc,      Q    ^ 


M" 


.  rt    jj  -r.    O 


ii  a>  ^ 
e3  oj  ■♦^ 


(U  aj  nj   ^ 

a,>  3  ^ 

O    O    p,  3 


12    ni  "§  -3    v"n'3    .  ~  J5  -i4 


a 

e3 


a> 

> 

c 

C3 

O 

tc 

■-r 

a 

S 

o 

^ 

n) 

^ 

.3 

>_:      a  =!> 
!:=!  a  o  2 


-3-3 


c3^ 


m 

a 

ta 

H 

a> 

o 

a 

4) 

u 

rt.2  ^"'^ 

=    O   C3   O 

>-i  fc-S  a 
3  ^  K  3 


a  *-  ^ ' 
o.o  o 

3 


3  9 


-a^  S^ 


'O  3 


E,3 


^   03 --3 
^    t.    o3 


S  °  3 
I— I -a  3 


OO    03    s 


&.=: 


2  ".H— I  "g 


o  2- 


a .«  oo  p 


«  U^ 


o 


J;  a  3  .^J3  J 


i-a:::  a 


U  o  pit 


a 

O   OQ   ?  ,— I 


O  Uh 


o 
ra  2 

;««a 
*S 
-73  a 


oo  S  p, 
«o  >,  o 


NEW   SUEGICAL   INSTRUMENTS. 


167 


O    O    q 
<— '    D    - 

■5       ® 


s  ;,  o  CD  s  i 


tc   eS  cS   ^.   O 


' "»  a 
I  "-I  a  „ 


SSg.2 


**    S    1>    l-l 
?.     CO    l-H 


c;  a  ^  S 


<u;^  a. 


I    . 


g  5R  o  !d    . 

-*^      S  o  a 


^2  M  -^  S 


•-^  S  >5  o 

SI?  ^"-^ 
a  o     ^-feo 

a  Sr;  5  "= 
a  -^s  o  -g  o 

£0   g   M   i=   aj 

'a  a     "SS 

,r>  ^  a>  c3 ,— I 


air3  o  c  fi 


i^a 

'S^cS 

^;^ 

1-3 

-l,^ 

^  3 

O*^ 

^ 

P5 

down  on 
d  opened 
t  out  the 

-§3 

a 

o     . 

a    r^  ""^ 

,—4 

■«  CS 

7.    Ic 
rector 
re  and 

153 

i 

5o 

^■^H 

a  « 

•  ^ 

§•-3 

arch  1,  1 
grooved 
the  stric 

p   OS 

05  m  '^ 

p,E,§ 

a)  ? 

g 

i-> 

jr,  o  -=;  "S  s 


3,a 


<y   ■»   ^   c3   _         „ 

£f.2  -S  '^  "  ^"^ 
i;"-'  a        _,  ci^ 


a>    tH    o 

t»  ,J3  a  >-< 


s  B  ®  S 


2  a-o  o  Mo^ 

o  t-  •«  a  t2  -tf 

j£  M  ^  "^  a      o 
4i  '3  -w       a>  'C  ai  tj 

rt  S  o  a  aoj^  oj 

0.3-+*  o  o  atj-u 


^      '--H    +3     CO 

^S   3-3  a^* 

e-S  =5  «  g 

'^~  S  S  a  2  ^ 
a  a  -r  -2  2  -2 

3   O   ^ts^   ^ 
Il'iS   f^«3   ..^ 


2  rt  <= 

a>  S  o 
o.  w  -w 


o  aj 


to 


«  s      « 

«  -^    ^    CQ 

a)  a  *^ 

.      «=    -3 
t^  aj  OS  P< 
"^  a  -^  cs  a 
2  S  iH     .2    • 
""•      o  a      o' 

-  -.2  -rt      i> 

,-1 '3    t<  •-'hn 


oi  ^  .^■5  "2  t"  a  9 

CO  o  ■'-<  .'tS  3  •'3  a  » 

_(  0)  o  ^  — .  aj 

-r  r,  tH  :=!  S  fe  aj  3 


aj  "3-3  3 

^2^-3 


P.5'2-3  a  3  fe>* 


5a 


>    D 


»  a  p,?,^ 


05  .3  ' 


6oa-j3 
aj  o 

as  s  S  '^     Ja  o  if 
5jCC!  w^  3  03  «  PhS 


a>.3 


a> 

3 

o 

:-• 

« 

a. 

•n 

a 

^ 

cS 

., 

a> 

p 

^ 

a 

S  aj,3 


^ 

<u 

!p 

^ 

Cm 
O 

a 

«J 

9-1 

■tJ 

a. 

'm 

a 

tS 

3 

Si 

Pm 


168 


OEIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 


O 


O 


X.'-  :S 


- ' 

a) 

ij 

ID 

"S 

.p 

-S 

4) 

Pq 

6 

s 

a 

^ 

■+-' 

o 

CO 

.■< 

MJ 

CnI 

a 

^ 

(Si 

o 

"X^ 

?5 

T) 

? 

fl 

-2 

;q 

1^ 

O   V 


S  g  2  a 


ce  =s  c  =* 


.r-«      C3     C^      (-H     — ^ 

>-  i-i  §  ^"75 
"al^^S 


2  >^ 


a  &c' 


=^  a  M-S 


re  £  a  o 


^  -^  a  aj  r„ 

a  o  a  -►^^ 


!  a^      S 
I  ©  S  a  2 


oj "  a 
a  _  o) 

M  'g    CD 

a  t^-"^ 


CO 

a  ^, 


CJ    oj 


a  a.  s 


<a  ■ 


^  .;  a 

•^  £  I  ^  s 

o  »- -S  a  ^ 
a^  >--^  ^ 

?  c3  -^  -ts  'Jj  a 

_2  a  ?  2  ^.o 


"-  ~  So 


«  "^  a 
^3 


u  a 


a'O 

O.J' 


o 


(U 


aabS3§ 

o  oj ,a  a  c3^ 
-j;  lo  fj  oS  a  'O 


a  ^  2 


a  >;>,-S    . 


s-i  ^  a  o  '—  • 
5  c!  cu  ~2.2 

f=^  s. "  a  S 
©"s  s'S  fe'S 

a  g  a  a  g  «u 

ce    O     '-'     rH     P"    t-t 

a  >  aZ:  c3  w 

a  •-  "S  S  -a  -a 
a  r~  ca  _a  "tf  .t- 

a  S  =5S  a 
<D  to  a  ?  a 
o  o  g  ^5 2 

•_g  •-;3  S  .5  Cm 


£  tSS  a 

a  a^  ci 

■_g    §    «    03 


O  >>    ^_r^ 

.  a  -a  'is  03 

CO  o  ♦^  -r;  K 
CO  aj        &  caO 

&  o  ^  ^  3 


^§r§^ 
§  a  ^"ss 
g-2i5 

.a  o  -c  M 

m        o 

J  "^  '■§  ^  si 

rt  t^  •,;:  2  " 

•  J'. 2  ""  c  S 

-  V,  1^  •::;  sc 

.  2  a  ^  £  J 


f=  c3  5  a 
a  ,r;  a  o 


t.  tf  "S  -^  u 
a  i;  ^  -i^^  o 

5-H  M'? 


03  1^ 


03   ■ 


CS  " 


a^^  a  "^ 
"S  a  1=  g  a 


S   02 


NEW   SURGICAL   INSTRUMENTS. 


169 


oo  «8,S        sS  ^ 
'"'  a  ^  60  05  -*^ 

*>•§  *f<l>  S'^  3 

n !"  a  "3  OS  In--- 


*^3  5>n  *"  5  a 


■»  o  1^  S 

>^  •£    05 

a;i"-.3 

Oh  is  .S  -2 


a  . 

ts  * 

03  2 


•3 -a 

o  *> 


=3-S|§^a 

-C    05  T— (    ^    ri 


w  a  K^  d  Si's 


Ol 


es 


•s  "^    «  a  -2  ■ 


p.  _ 

iT  "^  — ^    05 

*J  4>  to  cS  a  aJ 


-3  03  05  a  *^ 
-ir2       ^  o  «• 


'^:S  n-3 


S'-^.S  « 


03 -H   3   .-J 


„   w   aj  i£  • 

n    OJ    i-H    rti  ■ 


S  „  i;  <u  3  a  3 


S^  S-e  ^ 


QJ    r*    aj 


=S  a  s  >,=  5 


a  ®  £  ^-^S  o 


-JS  u-C  O   60 


Ol  u  o 


o3   o 


o  n  *  s-4:n3 


Ja.     TO     3     OJ 


a>  V  te  » 
03  PiS 


a  *^  w  « 

>-  —  a)  <u  -*^ 
3  fl—!  i!  ^ 
w  03^  Piv 


OQ 


5  a  P-2  g  s-^jg  3  3  =3.2  "  »3_ 

I— '   O)  a   o   >«:S^*H'niHfc«B*"a3 

t-  ao.i;  g  S^ai--^  S  3  §  «3^  ^    • 

O  O  3  gjrrj-u  _  ^-fcs  05 .3  a>  a-a!B.2 


"  a;  •-"  aj  c!  "  o 

>-  a-S  ^•-a  '^■■S 
oj  a  p.  V  k.  3  c£ 

rS  ^<  a  i,  a  aj  <u 

«  a  a-^-a.3  W) 
.« cs  g  3  -  3.2 
>,'^  •-  3  ^  3  "a 

"^  3        aj  "^  •"  3 

^  g  a  §.a  g,-^ 


®^   §13 

-a -5,:=;  a 

-w   4)   O  03 

« g;i3 

fl  o  o3  £? 

.2    «    05    § 

.212  p,fl 

O   ^   c3  « 

a  P<i3  8< 


13  a  ^  ■"    • 

g'0-3i3  g 
S.2  2  a  g 


.S  aj  aj  S 
T3  2ja-_a 


•^>      ^  f-i  "<  Qi  -^  ^  i^     .na 
i^*--^o--'3ajSs§*5oon-3 

13P<      i3opaJO'r<3^fc.'Si^<3»- 

^^•iaS.S.I^ii^-Ss^.a^ 

olgoa^^l^-^i-gg^.-a 

^^^  is  «  £-S  dgS-S-^-fi-aa) 
■«^g53i;i:S>4;aj^BoS.2-B 

Ph 


ft 

a^ 

— '    Sic 

-t^  3 

i 

3 

CO 

£ 

o 
Ml 

a 

2 

a 
a 

,2 
-a 

'a 

3 

o 

M 
o 
c 

!2; 

a> 

*b4 

o 

2 

u 

_05 

ca 

3 

a 

CS 
4) 

a 

05 

3 

-a 
3 

13 

.2  »- 
-Si 

13 

© 

o 

i) 

0) 

B 
3 

i^   O 

aj  >< 

to 

a 
5 

a 
© 

B 

<u 

?:-?.' 

13 

'^ 

3^ 

^ 

OS 

^ 

Ph 

^  60  6c3-2  "S  «3 

a  ^  ^  c3  "j;  te'Tw 
1^^  a'S  ^^,3 


"  m  oj  M  O  B'^ 

-m  83  eS  *  -»  1:  S 

13  year 
wollen 
penis 
;  fistul 
tinues 
the  pa 
5    the 

S  S  ^  a  §  o,^ 
'-'Ji  2  S  «  gg 

-.2  §.■"  ajJUif 

g ;  test 
a  coco 
a  man 
it  urin 
e  and 
d  infi 

aJ 

3 

05 

5c=  S  2  SS  S' 

•F^ 

"o  b  -w  «r  ii 


?  o  4)  Br:?  '1 
i3  a  *<  a  o  3 

03  2       "H   BtM 
aj  P<  aj  aj  •'-' 

S  ^1-1 1  §.2^1  § 

o|§^|g«^|;3 
2..^-s?3^sa-^ 

CS.2 


03  o   ..«  i 

.a  u- 


C3.rtSya-~iHOT_ra>^ 

^d-a  ^'C  o  5  aij2-a  i<'S 
So.=3  3-|ac3g)3S 

^"^I'll^iTsa^ 
-^-^-g-Saa^s-S  -S 

p<  00  a  -S  p,--«  +3  P<^  .a  00 

02 


3  ^g  3  OS'S 

tcS  ©-2  2^ 
3  a  so '''9  *- 

o  a    ^53 

^-3  ^ 

5  3.2  2"^  S 

-^^llila 

-  .  -S  i  2  '^  H 


>=«  o 


a*?!  a 


pS  aj^  ^'"iS^ 


i=*-i-Q 


^  =3  a-fi 


-o-c  2 
©  • 
© 


.2*  a 

_      -  0)    00 

03.3  -*).3   _^ 


12 


170  ORIGINAL   CONTRIBUTIONS   TO    OPERATIVE   SURGERY. 

GENERAL   REMARKS   ON   STRICTURE   OF   THE   URETHRA. 

For  twenty  years  of  my  professional  life  I  used  only  catheters 
and  bougies  for  the  treatment  of  strictures,  scarcely  thinking  of 
making  a  radical  cure ;  but  meeting  with  the  case  reported,  No.  1 
in  the  above  table  of  external  incisions,  I  was  compelled  to  make 
the  subject  a  special  study,  and  by  accident,  as  has  been  seen,  I 
discovered  the  mode  of  attaching  the  catheter  to  the  testicles,  and 
thereby  a  safe  and  easy  mode  of  retention.  This  enabled  us  to 
keep  bougies  in  as  long  as  we  wished,  and  we  treated,  during  the 
war,  several  cases  with  bougies  made  out  of  bars  of  lead,  putting 
in  one  size  after  another  until  we  enlarged  the  urethra  to  about 
No.  27,  which  gave  entire  relief  in  several  cases  which  are  still 
perfectly  cured.  After  the  war,  as  soon  as  we  could,  we  obtained 
a  complete  stricture  case,  having  Westmoreland's  urethrotome,  and 
six  sizes  of  steel  sounds,  with  triangular  ridges  on  their  curved 
portion.  These  we  used  with  great  difficulty,  and  ruptured  the 
mucous  membrane  without  dilating  the  urethra,  so  we  abandoned 
them,  and  sent  them  to  a  manufacturer  to  exchange  for  others. 
We  then  received  two  forms  of  dilators  moved  by  screws  at  the 
end ;  but  these  we  found  useless,  for  when  we  could  insert  them, 
we  could  use  our  urethrotome,  and  after  its  use  put  in  a  catheter, 
and  cured  our  patients  in  eight  days  by  internal  incision.  But  we 
met  with  some  that  we  could  not  enlarge  with  these  means  without 
resorting  to  the  old  plan  of  gradual  dilatation,  which  was  painful, 
tedious,  and  filthy,  so  we  procured  Holt's,  which,  as  now  improved, 
is  perfect,  and  very  simple.  Yet  we  did  not  have  as  good  success 
with  it  alone,  as  when  we  used  the  urethrotome  before  Holt's  dila- 
tor, first  cutting  the  stricture,  then  further  dilating  it,  and  finally 
putting  in  our  retention  catheter,  all  under  one  etherization,  keep- 
ing in  the  catheter  until  the  urine  burrowed  along  its  sides,  which 
it  did  usually  by  the  fourth  day,  giving  the  incision  and  ruptures, 
if  any,  time  to  heal  up.  By  the  fourth  day  it  would  become  loose, 
and  would  move  up  and  down  as  the  bladder  filled,  and  if  the  holes 
in  the  bladder  end  choked  up,  it  was  taken  out,  well  cleaned,  and 
put  back  after  the  fourth  day ;  we  tied  it  in  for  two  hours  each 
night  for  some  six  or  ten  days,  keeping  our  patient  easy  with 
morphine  while  confined  to  his  bed,  and  this  was  rarely  over  six 
days,  when  he  could  make  a  full  stream,  and  usually  returned  to 
his  business,  whatever  it  was.     By  this  time  patient  was  taught  to 


NEW   SURGICAL   INSTRUMENTS. 


171 


insert  tlie  catlieter  himself,  and  to  do  it  once  a  week,  and  let  it 
stay  for  two  hours.  By  these  simple  means  I  have  radically  cured 
all  cases  brought  to  me  for  the  last  ten  years,  that  I  could  insert 
the  end  of  Westmoreland's  urethrotome  (see  Fig.  45,  fig.  52. 
1,  page  156),  and  have  never  resorted  to  external  inci- 
sion unless  there  were  fistulse,  when  I  have  invariably 
cut  the  strictures  on  a  grooved  director,  or  Fig.  45,  4, 
page  156.  If  in  the  body  of  the  penis  cut  in  the  mem- 
branous portion  with  the  urethrotome,  and  then  tie 
in  my  catheter,  and  let  the  parts  heal  up  over  it. 
After  the  urethra  enlarges  so  the  catheter  can  be  put 
in  easily,  it  is  taken  out  and  inserted  daily,  as  in  cases 
of  internal  incision.  In  the  thirty-one  external  opera- 
tions, no  deaths,  and  but  one  death  in  the  eighty-six 
internal  incisions,  being  a  mortality  of  one  in  one  hun- 
dred and  seventeen  cases  since  I  began  the  use  of  my 
retention  catheter ;  and  certainly  my  cases  were  as 
bad  as  any  ever  seen,  as  will  be  found  by  reading  the 
cases  reported  in  the  tables.  With  this  catheter  no 
infiltration  can  take  place,  and  consequently  no  sloughs 
or  abscesses  have  formed  when  it  was  used ;  and  hence 
the  great  success  I  have  had  in  both  internal  ureth- 
rotomy and  external  urethrotomy,  having  cured  all 
except  one  case  —  eighty-six  internal  incisions,  and 
thirty-one  external.  Then,  to  treat  all  cases,  I  need 
and  use  only  a  few  instruments.  I  have  never  an- 
noyed my  patients  with  the  filiform  bougies,  though 
I  think  they  should  be  used  by  timid  surgeons,  and 
by  all  who  have  not  a  thorough  knowledge  of  the 
urethra  and  its  annexes ;  but  while  getting  the  urethra 
large  enough  for  dilators  and  urethrotomes  we  can 
cure  our  patient  with  the  simple  means  we  have  used, 
and  without  half  the  pains.  To  diagnose  a  stricture 
we  have  found  the  catheters  alone  sufficient,  but  we  use  urethra-meter. 
the  olive  sound,  or  Dr.  Otis'  instrument  (Fig.  52),  called  by  him 
the  urethra-meter ;  it  is  an  admirable  instrument,  and  simple  in  its 
use.  I  wish  I  could  say  as  much  for  his  dilators,  but  in  my  opinion, 
they  are  not  to  be  compared  to  Holt's  improved,  either  in  efficiency, 
facility,  or  safety.  The  sides  will  spring,  and  will  pinch  or  tear  the 
mucous  membrane  in  its  withdrawal,  as  did  the  two  I  used,  and  aban- 


172 


ORIGINAL  CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 


doned  as  useless,  in  comparison  with  Holt's.  Dr.  Gouley's  urethro- 
tome (Fig.  53)  is  a  good  instrument  when  one  has  a  very  tight  stric- 
ture, and  wishes  to  avoid  external  incision,  especially  if  the  stricture 
is  in  the  part  anterior  to  the  bulbous  portion ;  beyond  that  it  is  not 
half  so  safe  an  instrument  as  Westmoreland's.  With  the  latter 
■pjQ  53  one  cannot  do  any  harm  if  he  be  a  good  anatomist, 

and  holds  the  instrument  with  its  point  to  the 
pubis,  and  handle  in  a  line  with  the  umbilicus. 
The  only  objection  to  this  instrument  is  the  weak 
point  at  the  part  that  moves  the  blade,  and  the 
blade  sometimes  gets  out  of  its  director,  both  of 
which  I  have  proposed  to  remedy  by  adopting 
Otis'  sliding  staff  for  the  screw,  and  putting  a  ring 
round  under  the  blade  so  it  cannot  leave  the  staff. 
We  are  having  these  improvements  made. 

Dr.  Otis  has  done  a  good  work  with  this  instru- 
ment, in  estabhshing  the  length  and  size  of  the 
urethra,  and  has  given  us  a  table  of  strictures 
varying  so  much  from  those  we  have  given,  that 
we  quote  him  in  full  on  these  points,  showing  that 
these  facts  are  not  settled,  and  require  more  ex- 
amination to  settle  the  disputed  points. 

"  I  have  said  that  there  exists  a  constant  rela- 
tion between  the  size  of  the  flaccid  penis  and  the 
capacity  of  the  urethral  canal.  During  the  past 
year  I  have  subjected  more  than  one  hundred 
urethrse  to  a  careful  examination  on  this  point, 
with  the  following  results,  to  which  there  has  not 
been  found  a  single  exception,  viz. : 

"That,  when  the  circumference  of  the  flaccid 
penis  was  three  inches,  the  circumference  of  the 
urethral  canal  was  found  to  be  at  least  30  of  the 
French  scale.  When  it  was  3|-  inches  the  urethra 
had  a  capacity  of  32.  When  it  was  3J,  the  capa- 
city would  be  34—31=36;  4  inches =38.  When 
Dr.  Gouley's  Ureth-  it  was  4 J  to  4J  inches  in  circumference  the  capa- 
city of  the  urethra  would  equal  40,  or  more.  In 
every  case  the  urethral  calibre  was  over  rather  than  under  the 
figures  above  given.  In  a  considerable  majority,  contraction  of 
the  meatus  (either  congenital  or  from  previous  inflammatory 
changes)  was  present,  and  in  these  cases  the  measurements  were 
made  with  the  urethra-meter  or  after  division  of  the  contraction. 
The  value  of  the  urethra-meter  in  ascertaining  the  actual  calibre 


FEW  SURGICAL   INSTRUMENTS. 


173 


of  the  urethra,  notwithstanding  the  presence  of  stricture  or  con- 
traction of  the  meatus,  cannot  be  overrated;  it  is  with  this  instru- 
ment that  the  proportionate  relations  of  the  urethral  calibre  and 
the  size  of  the  flaccid  penis  have  been  confirmed.  With  it  and  the 
metallic  bulbous  sound,  the  thorough  examination  of  any  present- 
ing urethra  may  be  made,  and  the  precise  locality  and  value  of 
every  deviation  from  its  normal  calibre  be  positively  determined. 
Having  then,  in  any  given  case,  made  out  the  number,  size,  and 
locality  of  strictures,  the  desideratum  is  to  find  an  instrument 
which  will  completely  divide  them,  with  as  little  injury  to  the  adja- 
cent healthy  structures  as  the  possibilities  of  the  case  will  admit." 

''One  hundred  cases  of  urethral  strictures,  comprising  two  hun- 
dred and  three  operations,  upon  two  hundred  and  fifty-eight  stric- 
tures, have  been  carefully  collated,  from  my  books  of  daily  record, 
by  my  assistant.  Dr.  J.  Fox,  and  subjected  to  a  subsequent  critical 
revision  by  myself. 

The  careful  tabular  analysis  of  these  cases,  which  is  presented 
with  this  paper,  embraces  the  following  points:  1.  Age  of  patient. 
2.  Cause  of  stricture.  3.  Locality  and  size.  4.  Number  in  each 
case.  5.  Normal  calibre  of  urethra.  6.  Complicating  diseases  or 
conditions  at  date  of  operation.  7.  Symptoms  at  date  of  operation. 
8.  Accidents  following  operation.  9.  Results  of  operation,  as 
determined  by  a  subsequent  re-examination  with  the  full-sized 
bulbous  sound,  at  periods  varying  from  three  weeks  to  three  years. 
10.  Results  as  shown  by  continued  relief  from  all  symptoms,  where 
no  instrumental  re-examination  has  been  practicable.  Not  to 
absorb  too  much  time,  I  will  only  allude  now  to  a  few  points  of 
greatest  importance  in  connection  with  the  facts  which  are  devel- 
oped by  this  summary : — 

"  1st.  It  will  be  found  that  out  of  the  258  strictures,  52  were  in 
the  first  quarter  inch  of  the  urethra;  63  in  the  following  inch,  viz., 


48  from  1^  to  2^ , 


48  from  2i  to  3i 


14  from  41  to  5^ ;  8  from  5^  to  6^ ;  6  from  6i  to  1, 


19  from  3|  to 


from  \  to  1\ 
4-1  • 
* '  .  .    -         -  -         -  -         - 

"Authorities  claim  that  the  great  majority  of  urethral  strictures 

are  found  in  the  vicinity  of  the  bulbo-membranous  junction,  and  cite 
various  possible  causes  for  their  frequency  in  this  locality. 

"  By  the  above  statement  it  will  be  seen  that  they  occur,  as  would 
naturally  be  expected,  in  greatest  frequency  where  the  inflamma- 
tion begins  the  earliest,  and  rages  the  hottest,  and  gradually  dimin- 
ish in  frequency  in  the  deeper  portions  of  the  canal. 

"2d.  Of  the  normal  calibre  of  the  urethra: — 


22  Mm.  circumference 1 

28  "  "  3 

29  "  "  ..'...    1 

30  "  "  18 

31  "  "  25 

32  "  "  19 

33  "  "  3 

|34  "  "  16 


36  Mm.  circumference 1 

37  "  "  2 

38  '<  "  6 

40    "  "  1 

Not  noted 4 

100 


174         ORIGINAL   CONTEIBUTIONS   TO   OPERATIVE   SURGERY. 

"Thus,  it  will  be  seen  that  in  ninety-nine  carefully  measured 
cases  the  average  normal  calibre  was  31.84  (deducting  the  case  of 
child  of  ten  years,  22  m.),  nearly  32  of  the  French  scale. 

"  3d.  Of  the  accidents  following  operations :  Hemorrhage  in 
four  cases;  prostatic  abscess  in  three  cases;  curvature  of  penis 
during  erection  in  three  cases ;  urethritis  in  two  cases ;  diphtheritic 
deposit  of  wound  in  three  cases;  urethral  fever  in  seven  cases; 
retention  in  one  case. 

"  4th.  Slight  urethral  fever  has  followed  the  operation  but  seven 
times.  Six  times,  when  for  stricture  in  the  curved  portion  of  the 
urethra;  once  only,  when  the  operations  were  in  the  pendulous 
portion  of  the  organ,  and  this  occurred  in  a  malarious  subject. 
This  leads  me  to  remark,  that,  in  my  experience,  operations  con- 
fined to  the  pendulous  urethra,  are,  as  a  rule,  never  followed  hy 
constitutional  disturbance,  even  when  six  or  seven  strictures  are 
divided  at  the  same  sitting.  But,  to  insure  this  result,  no  instru- 
ment, not  even  a  sound  for  exploratory  purposes,  should  be  passed 
into  the  bladder,  during,  or  immediately  subsequent  to  the  opera- 
tion. 

"  5th.  Three  operations  were  followed  by  prostatic  abscess.  In 
one  of  these  cases,  the  patient,  who  was  a  physician,  sailed  for  the 
West  Indies  in  about  a  week  after  the  operation  (which  was  for  a 
single  stricture  near  the  meatus),  and  reported  trouble  of  the  pros- 
tate coming  on  soon  after,  he,  meanwhile,  using  a  sound  himself,  to 
prevent  recontraction. 

"  6th.  Curvature  of  the  penis  downward  followed  in  three  cases 
where  numerous  strictures  were  divided,  but  this  trouble  occurring 
during  erections  was  unattended  with  pain  and  passed  off  entirely 
within  from  two  to  six  months  after  the  operation,  in  two  cases. 
In  one  case,  at  the  end  of  a  year,  there  was  slight  curvature,  but 
gave  no  trouble. 

*'  7th.  Urethritis  in  two  cases ;  one  followed  an  operation  at  the 
meatus,  and  was  set  up  by  forcible  use  of  a  tube,  by  the  patient,  to 
prevent  recontraction.  It  lasted  acutely  for  three  weeks,  and  was 
followed  by  a  gleet,  lasting  four  months,  which  finally  ceased  after 
a  second  operation,  required  by  the  recontraction  which  had  taken 
place. 

"The  second  followed  an  operation  upon  four  strictures,  and  oc- 
curred within  a  week.  This  was  complicated  by  the  presence  of  a 
diphtheritic  deposit  upon  the  wound,  near  the  meatus.  It  was  sup- 
posed to  have  resulted  from  a  similar  action  in  the  wound  of  the 
deeper  portions  of  the  canal. 

8th.  Diphtheritic  deposit  occurred  upon  the  wound  in  two  other 
cases,  lasting,  under  treatment  by  iron  and  quinine  generally,  and 
applications  of  the  strong  acetic  acid  locally,  about  two  weeks,  and 
was  followed,  in  both  instances,  by  a  recontraction  of  the  stricture. 


NEW   SURGICAL   INSTRUMENTS. 


175 


Time  after  Operation. 

No.  of 

Cases. 

No.  of 

Strictures 

Time  after  Operation. 

No.  of 

Cases. 

1 
1 
4 
1 
4 
1 
1 
1 

No.  of 

Strictures. 

3   years, 

2i    " 

li  year, 

13    months,     .     .     . 

I    year, 

10    months,      .     .     . 

9      "        

8      "          .... 

1 
1 
2 
3 
4 
1 
1 
1 
2 
7 

4 

7 

8 

14 

7 

2 

1 

1 

10 

21 

5    months,    .... 
4      "          .... 

3      "        

2i    "          .... 

2  "        

1  month,  .... 

3  weeks,      .... 

2  "          .... 

7 

3 

15 

10 

11 

1 

5 

1 

7      "        

6      "          .... 

37 

128 

In  tHrty-one  cases  none  of  the  strictures  had  recontracted.     In 
six  cases  most  of  them  had  been  absorbed,  while  some  remained. 

EESULT. 

Cures.    Re-examined.    No  reeontraction, 31  cases. 

Cures.  Patient  perfectly  well  when  last  heard  from.  No  re- 
examination,           52      " 

Perfect  relief  for  a  length  of  time.      Return  of  symptoms. 

Re-examination,     Stricture  found  to  have  recontracted,      4      " 

Perfect  relief  for  a  length  of  time.    Return  of  symptoms.     No 

re-examination, _..._.      5 

Relief  of  most  symptoms.     Some  remaining.     Patient  still 

under  treatment, 4 

Partial  relief, 3 

Results  not  known, 1 

It  will  be  seen  from  these  statistics  that  the  results  of  treatment 
justify  in  the  completest  manner  all  that  has  been  heretofore 
claimed  by  me  for  the  method.  In  point  of  gravity  it  will  be  seen 
that  cutting  operations  for  the  division  of  stricture  in  the  pendu- 
lous portion  of  the  urethra  (where  the  great  majority  of  strictures 
are  found)  compare  most  favorably  with  all  other  modes  of  treat- 
ing stricture,  and  cannot  be  considered  as  exposing  the  patient  to 
more  peril  or  inconvenience  than  simple  gradual  dilatation  by 
means  of  graduated  soft  bougies  or  sounds.  In  regard  to  the 
advantages  of  operations  as  quoted,  they  are  manifold,  to  the 
patient  as  well  as  to  the  surgeon ;  comparatively  painless,  except 
near  the  meatus;  speedily  performed,  involving  at  most  but  a  few 
days'  loss  of  time  (often  not  even  a  day,  where  the  stricture  is 
single  and  recent).  The  after  treatment,  consisting  only  of  sepa- 
ration of  the  wound  throughout  its  extent  by  the  easy  passage  of  a 
full-sized  steel  sound  daily,  or  every  other  day,  until  healing  is 
complete. 

Speaking  of  the  retention  of  a  catheter.  Prof.  Gouley,  of  New 
York,  uses  the  following  language,  which,  we  must  say,  does  not 
correspond  with  our  experience : — 


I  believe  that  the  retention  of  a  catheter  in  the  bladder,  after 


176         OEIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 

perineal  urethrotomy,  even  for  forty-eight  hours,  is  not  only  unne- 
cessary, but  harmful.  Unnecessary,  because  it  does  not  fulfill  the 
supposed  indication  of  preventing  the  flow  of  urine  through  the 
wound,  and  because  the  contact  of  the  urine  with  the  fresh-cut 
surfaces  does  no  harm,  as  is  exemplified  by  lateral  and  median 
lithotomy,  and  also  by  the  cases  which  have  been  detailed.  Harm- 
ful, because  the  presence  of  the  instrument — a  foreign  body — in 
the  bladder,  sometimes  causes  ulceration  and  perforation  of  that 
viscus,  and  does  give  rise  to  inflammation  and  to  urethral  fever." 

This  is  no  doubt  true  with  the  gum  catheter  retained  in  the  old 
way  and  of  small  size,  but  with  the  full  size,  retained  by  our  mode, 
this  does  not  occur. 

We  have  given  a  table  of  some  of  our  cases  after  his  formula,  so 
the  reader  can  compare  statements.  We  had  trouble  whenever  our 
catheter  was  taken  out  and  allowed  to  remain  out  for  the  first  ten 
days ;  being  difficult  to  reintroduce  and  very  painful.  Our  general 
plan  was  to  remove  it  every  day  and  clean  it  out,  then  reinsert  it, 
tying  it  in  by  means  of  tape  in  the  eyes  and  around  the  testicles. 
By  this  means  the  catheter  was  pushed  down  by  the  bladder  into 
the  urethra,  and  there  it  remained,  and  could  not  wound  the  blad- 
der itself.  By  pushing  it  up,  the  urine  would  flow,  and  there  was 
no  trouble.  When  we  did  not  keep  the  catheter  in,  we  put  it  in 
daily  and  kept  it  there  for  at  least  half  an  hour,  and  whenever  we 
violated  this  rule  we  had  trouble.  In  case  four,  P.  M.,  a  distin- 
guished lawyer,  the  catheter  was  removed  only  once  in  ten  days, 
and  there  was  a  perfect  cure  with  no  bad  symptoms.  In  case  three, 
T.  R.  N.,  when  the  catheter  was  taken  out,  it  was  difficult  to  rein- 
troduce and  very  painful,  but  by  reinserting  and  keeping  it  in, 
there  was  no  more  trouble,  and  the  case  was  perfectly  relieved,  and 
when  we  wished  to  take  it  out,  he  was  unwilling,  for  fear  of  like 
sufiering.  In  case  five,  when  taken  out,  pain  was  severe  and  fever 
set  up ;  but  on  reinserting  the  catheter,  the  fever  subsided  and 
the  patient  did  well.  He,  too,  was  unwilling  to  have  it  taken 
out  to  be  cleaned.  From  this,  we  conclude  that  the  retention  of 
the  catheter  is  best  and  safest,  and  can  do  no  harm  if  not  tied  in 
immovably.  If  tied  to  the  testicles,  no  great  pressure  is  possible ; 
but  if  retained  too  long,  it  will  cause  suppuration,  and  its  removal 
will  give  great  relief. 

We  make  further  quotations  from  Dr.  Gouley  that  we  highly 
approve  of,  and  they  speak  for  themselves  : — 

"  The  rough  use  of  the  sound  [we  use  the  catheter  alone],  will, 


NEW   SUEGICAL   INSTEUMENTS,  177 

sometimes,  bring  on  orchitis.  The  too  frequent  introduction  of  the 
instrument  also  occasionally  produces  this  result.  Another  fact, 
worthy  of  remembrance,  is,  that  the  sound  should  not  be  retained 
in  the  urethra  longer  than  five  minutes.  There  are  patients  who 
are  liable  to  attacks  of  orchitis  in  spite  of  the  greatest  care  and 
gentleness  in  the  use  of  the  sound.  This  may  sometimes  be  averted 
by  advising  them  to  take  the  following  precautions :  1.  Use  a 
diluent  drink  through  the  day  preceding  and  the  one  following  the 
introduction  of  the  instrument.  2.  Take  a  warm  hip-bath  imme- 
diately after.  3.  Support  the  testicles  with  a  suspensory  bandage. 
4.  Eemain  in  the  horizontal  posture  for  twelve  hours. 

"In  the  case  of  working  men,  or  others  who  are  obliged  to  be 
about  through  the  week,  it  is  well  to  recommend  them  to  pass  the 
instrument  every  Saturday  evening,  after  working  hours,  that  addi- 
tional rest  may  be  had  on  the  day  following,  if  necessary,  without 
loss  of  valuable  time." 

This  we  warmly  recommend. 

"  The  term  large  instrument  is  only  relative ;  the  diameter  of 
the  sound  should  be  proportionate  to  that  of  the  uncontracted  part 
of  the  urethra,  and,  if  the  meatus  is  abnormally  narrow,  it  should 
be  freely  incised  longitudinally  along  its  floor,  and  the  caliber  of 
the  canal  then  estimated.  Some  urethrse  will  only  admit  Xo.  30, 
while  others  are  sufficiently  capacious  to  permit  the  easy  introduc- 
tion of  No.  36,  an  instrument  of  nearly  ten  and  a  half  millimetres 
(over  three-eighths  of  an  inch)  in  diameter. 

"  To  arrive  at  a  correct  appreciation  of  the  value  of  the  operation 
of  external  division  of  strictures  of  the  urethra,  it  is  necessary  to 
consider :  1.  Under  what  circumstances  the  operation  is  justifiable. 
2.  What  amount  of  danger  attends  its  performance.  3.  How  far 
it  is  entitled  to  be  considered  as  a  means  of  cure. 

"  Sir  Henry  Thompson,  after  whom  the  last  two  inquiries  are 
phrased,  says  :  '  It  has  been  stated  that  the  hazard  to  which  the 
patient's  life  is  exposed  by  it  (the  operation)  is  too  great  to  be  in- 
curred for  the  sake  of  obtaining  a  cure  of  his  complaint.  This 
view  has  not  improbably  arisen,  in  some  measure,  from  the  still 
common  but  erroneous  habit,  already  alluded  to,  of  confounding 
external  division  of  a  permeable  stricture  upon  a  sound  with  the 
operation  upon  an  impassable  one  without  it.' 

"Professor  Van  Buren,  in  a  published  lecture,  remarks:  'The 
dangers  of  this  operation  depend  upon  the  conditions  which  neces- 
sitate its  performance,  rather  than  upon  the  proceeding  itself.  If, 
as  is  always  desirable,  its  necessity  has  been  foreseen,  and  time 
secured  for  the  examination  of  the  internal  organs,  and  ample  pre- 
paration made,  the  danger  is  trivial;  but  if,  on  the  contrary,  as 
often  happens  in  hospital  practice,  the  patient  falls  into  the  surgeon's 
hands  with  prolonged  retention  or  extravasation  of  urine,  from 


178         ORIGINAL   CONTRIBUTIONS   TO  OPERATIVE   SURGERY. 

recklessness  or  neglect,  the  operation  is  likely  to  be  much  less 
favorable.  And  if,  in  addition  to  these  serious  complications,  the 
stricture  should  prove  to  be  impassable,  and  the  operation  is  neces- 
sarily undertaken  without  any  guide  to  the  bladder,  it  becomes 
one  of  the  most  difficult  and  uncertain  proceedings  of  surgery. 
The  alternative  of  puncture  of  the  bladder  from  the  rectum,  or 
above  the  pubes,  may,  in  rare  cases,  be  adopted  from  necessity; 
but  these  measures  afford  only  temporary  respite,  inasmuch  as  they 
leave  the  stricture,  the  cause  of  all  the  trouble,  unrelieved.' 

"  Dr.  Markoe  says  :  '  It  must  be  evident  to  you  that  the  success 
or  failure  of  it  depends  upon  the  condition  of  the  patient  for  which 
the  operation  becomes  necessary ;  that  the  dangers  of  the  operation 
itself  can  hardly  be  separated  from  those  of  the  disease  for  which 
it  is  performed.  Being  a  last  and  only  resort  for  a  desperate  con- 
dition of  things,  we  cannot  select  our  cases  nor  prepare  them  for 
the  operation.' 

"  Professor  S.  D.  Gross  observes :  '  The  operation  is  by  no  means 
free  from  danger,  and  requires  the  most  consummate  skill  for  its 
successful  execution.  None  but  a  madman  or  a  fool  would  attempt 
it,  unless  he  had  a  profound  knowledge  of  the  anatomy  of  the  parts, 
and  a  thorough  acquaintance  with  the  use  of  instruments.' 

"  I  have  quoted  the  opinions  of  these  distinguished  surgeons — 
pertinent  to  the  estimate  of  the  operation — as  fairly  mirroring  the 
advanced  mind  of  the  profession,  and  that  I  may  express  my  gen- 
eral accordance.  But  I  must  insist,  most  emphatically,  upon  a 
correct  interpretation  of  the  words  '  the  operation  being  a  last  re- 
source.' While,  beyond  all  question,  the  conscientious  surgeon 
must  propose  to  himself  all  other  available  and  justifiable  means  of 
relief,  yet,  when  these  have  been  tried  and  have  failed,  the  knife  is 
not  only  the  '  last  resource,'  but  the  only  resource,  and  must  be 
promptly  and  resolutely  applied.  The  operation  has  often  been 
deferred  so  long,  that  the  bladder  and  kidneys  have  become  irre- 
parably damaged  by  the  action  of  the  frequently-retained  urine, 
and  finally  the  knife  is  used  when  all  operative  procedures  are  con- 
tra-indicated. This  long  delay  accounts,  in  a  great  measure,  as  I 
believe,  for  the  large  percentage  of  mortality  which  has  followed 
the  operation,  and  has  brought  it  into  disrepute.*  So  great  was 
formerly  this  mortality,  that,  toward  the  emi  of  the  last  century, 
such  authorities  as  Desault  and  Ohopart  positively  condemned  the 
operation,  and  it  fell  into  disuse.  Its  revival  in  our  country  is  due 
to  the  late  Dr.  Alexander  H.  Stevens,  who  performed  it  'with 
entire  success,  after  the  common  modes  of  treatment  had  failed,'  in 
the  year  1817. 

"  The  advances  that  have  been  made  in  our  knowledge  of  the 
pathology  and  treatment  of  stricture  of  the  urethra  indicate  a 
moderate  and  middle  course  to  be  pursued.     It  is  now  believed,  by 

[*  Case  seven  is  a  case  in  point.] 


NEW   SUEGICAL   INSTEUMENTS.  179 

conservative  and  judicious  surgeons,  that  the  class  of  cases  which 
require  the  operation  is  small,  and  that,  even  in  these  cases,  before 
resorting  to  the  knife,  gradual  dilatation  and  all  other  available 
means  of  relief  should  be  thoroughly  and  faithfully  tried.  Imper- 
meability, resiliency,  or  great  irritability  of  strictures,  are  indica- 
tions by  which  these  surgeons  are  influenced  in  the  adoption  of  this 
mode  of  treatment.  In  impassable  strictures,  attended  with  reten- 
tion or  extravasation  of  urine,  or  where  there  exist  obstinate  uri- 
nary fistulse,  few  now  entertain  any  doubt  of  the  propriety  of  the 
operation.  Narrow  strictures,  from  traumatic  lesions,  are,  it  is 
thought,  sufficient,  as  a  general  rule,  to  warrant  the  external  peri- 
neal division." 

We  have  before  given  our  opinion  on  this,  as  opposed  to  all  ex- 
ternal incision,  when  the  smallest  bougie  can  be  passed  into  the 
bladder,  and  know  that  unless  there  is  an  open  external  fistula,  as 
the  result  of  stricture,  all  cases  may  be  cured  by  internal  incision. 

"  On  the  other  hand,  those  extremists,  who  maintain  that  per- 
meability to  instruments  necessarily  contra-indicates  the  operation, 
meet  with  very  few  supporters.  The  aim  of  the  majority  of  sur- 
geons, in  our  day,  is  to  endeavor  to  pass  in  a  conductor,  but,  when 
this  is  not  practicable,  they  operate  without  it,  for  the  double  pur- 
pose of  dividing  the  stricture,  and  of  relieving  or  averting  reten- 
tion of  urine. 

"  In  three  hundred  and  forty-five  operations  of  external  division 
of  strictures,  performed  by  American  surgeons,  two  hundred  and 
thirty-three  of  which  were  done  without  a  conductor,  there  were 
forty-one  deaths,  about  twelve  per  cent.  The  assigned  causes  of 
death  were  :  advanced  disease  of  the  bladder  and  kidneys  in  twenty- 
two  cases ;  pyaemia  in  fifteen  cases ;  erysipelas  and  pyaemia  in  one 
case ;  intra-pelvic  abscess  and  pyaemia  in  one  case,  and  thrombosis 
in  two  cases. 

"According  to  the  late  Prof.  Miller,  of  the  University  of  Edin- 
burgh, the  following  are  the  dangers  which  attend  the  performance 
of  the  operation :  1.  Hemorrhage.  2.  Infiltration  of  urine.  3. 
Abscess  in  or  near  the  wound,  leading  perhaps  to  fistula  or  irrita- 
tive fever.    4.  Intra-pelvic  abscesses.     5.  Erysipelas.    6.  Pyaemia." 

We  fully  approve  of  all  said  here,  and  think  there  is  but  little 
danger  in  the  disease  or  from  the  operation,  when  well  performed. 
In  our  thirty-one  cases,  six  were  impermeable  to  all  instruments, 
and  the  strictures  were  removed.  Of  the  three  who  died,  two  came 
to  their  death  by  entirely  foreign  causes — one  measles,  the  other 
rheumatism ;  so  we  may  say  all  six  were  cures  so  far  as  their  stric- 
tures were  concerned,  even  of  those  that  were  impermeable.     Of 


180 


OEIGINAL   CONTRIBUTIONS   TO  OPERATIVE   SURGERY. 


the  others  that  were  permeable,  in  three  there  were  no  bad  symp- 
toms, and  all  but  one  recovered.  In  all  the  internal  incisions,  ab- 
scesses were  prevented,  except  in  two  cases.  The  seventh  case  died 
from  gangrene  produced  before  the  operation. 

INCISION   AS  A   MEANS   OF   CURE. 

"  The  third  consideration  must  now  come  up  for  investigation, 
namely — how  far  the  operation  is  to  be  considered  as  a  means  of 
cure.  Sir  Henry  Thompson  makes  the  three  following  points :  1. 
It  may  fail  to  afford  relief.  2.  It  may  be  cured  for  a  short  period, 
and  afterward  be  followed  by  a  relapse.  3.  It  may  effect  a  per- 
manent cure. 


Fig.  54. 


C^tl^  WraCxn^s^ 


Holt's  Original  Instruments. 

"  It  is  now  believed  that  the  operation  will  afford  permanent 
relief  only  so  long  as  the  patient  continues  to  use  a  full-sized  in- 
strument at  intervals  of  a  week  or  two ;  and,  as  far  as  I  am  aware, 
there  is  no  method  of  treatment  as  yet  devised,  for  obstinate  stric- 
ture of  the  urethra,  which  will  effect  a  permanent  cure,  without 
the  occasional  use  of  a  sound." 


NEW  SUEGICAL   INSTRUMENTS. 


181 


Fig.  55. 


In  our  cases,  all  are  perfectly  well,  up  to  the  present  date,  and 
have  never  suffered  from  any  inconvenience  since,  except  case  five, 
who  says  he  has  no  difficulty  in  making  water,  but  there  is  a  slight 
discharge  and  some  pain.  He  is  still  using  a  catheter  once  a  week. 
We  operated  on  this  case  by  external  incision,  but  were  discharged 
the  day  after  we  operated,  and  he  is  still  a  sufferer. 

Holt's  original  dilators  are  shown  in  Fig.  54.  Seldom  used  now, 
as  the  curved  instrument  used  by  us  is  far  better.  Fig.  55  shows 
the  canulated  sound  for  cauterizing  the  urethra  and  prostate  gland. 
The  sounds  2  and  4  are  made  to  slide  out  with  a  caustic  at  their 
end,  and  sKde  out  at  the  point 
needed.  Fused  nitrate  of  silver  is 
usually  used ;  should  only  be  kept 
in  a  few  seconds,  and  withdrawn 
in  its  cannula,  as  1  and  5. 

ENLARGEMENT    OF    PROSTATE 
GLAND. 

Probably  there  is  no  form  of  dis- 
ease of  the  urethra  or  its  annexes 
that  is  more  troublesome  or  dan- 
gerous than  mere  enlargement  of 
the  prostate  gland.  Old  persons 
are  especially  liable  to  it.  It  is 
known  by  a  retention  of  urine; 
the  bladder  can  never  be  entirely 
emptied,  even  with  a  catheter. 
Upon  sounding,  a  straight  sound 
or  even  a  common  sound  cannot 
be  carried  to  the  bladder.  The 
enlargement  can  be  usually  felt 
through  the  rectum  by  the  finger. 
Sir  Henry  Thompson  teaches  that 
the  gland  is  composed  of  only  two 
lobes,  and  not  three,  as  usually 
taught,  and  that  the  enlargement 
is  central  and  fills  up  the  space  for- 
merly occupied  by  the  urethra, 
bulging  out  into  body  of  bladder,  making,  as  it  were,  a  backwater, 
over  which  the  urine  cannot  flow,  unless  the  bladder  is  very  full, 


Canulated  Sound,  for  Cauterizing 
Urethra  and  Prostata  Gland. 


182 


ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 


and  then  it  often  presses  up  so  as  to  entirely  prevent  any  discharge. 
A  common  catheter  cannot  be  inserted  without  the  finger  in  the 
rectum  to  push  the  point  up.     This  necessitates  a  flexible  catheter 


Fig.  56. 


Bulbous-pointed  Flexible  Catheter. 

of  india-rubber  (Fig.  56),  with  a  small,  bulbous  point,  or  a  verte- 


FlG.  57. 


Vertebrate  Silver  Catheter. 


brate  silver  (Fig.  57),  or  Prof.  Gross'  prostatic  catheter,  which  is, 
perhaps,  the  best. 

The  treatment  is  precarious  and  uncertain,  and  mostly  palliative, 
such  as  regularly  drawing  off  the  water  with  some  one  of  the 


Fig.  58. 


O.T/SMANN  &C0. 
Gouley's  Ligating  Instrument. 


catheters  above  named.  Prof.  Gouley  ligates  the  posterior  part,  as 
we  remove  a  polypus,  with  an  instrument  of  his  invention  (Fig.  58). 
I  pass  the  sound  into  the  bladder  by  the  urethrotome,  and  cut  the 


NEW   SUEGICAL   INSTRUMENTS. 


183 


eWargement  back  and  forth,  right  and  left,  witli  the  urethrotome 
blade,  then  put  in  my  No.  30  retention  catheter,  and  keep  it  in  for 
ten  days.  This  gives  relief,  but  the  catheter  must  be  then  used 
once  a  day. 


Mr. 


CASE   OF   SUPPURATION  OF   PROSTATE   GLAND. 

— ,  aged  forty-five,  of  Danville,  Va.,  traveling  in  Texas 


last  winter,  was  taken  with  a  discharge  of  pus  and  mucus,  with 
heat  and  a  burning  sensation  in  the  urethra,  with  difficulty  in 
making  water ;    supposed  he  had   gonorrhoea,  for  which  he  was 


Fig.  59. 


Sound,  -with  Guide. 


Fig. 


Exploring  Catheter  and  Sound. 


Fig.  61, 


Double  Canulated  Catheter. 

treated,  and  a  flexible  catheter  given  him  to  draw  off  his  water. 
In  this  condition  he  came  to  Galveston,  and  put  himself  under  Dr. 
R.'s  care.  He  had  fever,  and  complained  of  heat  and  burning  in 
the  prostate ;  was  catheterized  by  Dr.  E.,  who  had  no  difficulty  in 
passing  a  No.  17  catheter,  and  drawing  off  his  water.  He  did  not 
improve,  and  Dr.  K.  called  me  to  see  him.  Had  fever,  and  much 
pain ;  passed  catheter  with  no  difficulty ;  got  worse  and  could  not 
pass  his  urine ;  put  catheter  in,  and  a  great  deal  of  offensive  pus 


184         ORIGINAL   CONTRIBUTIONS  TO   OPERATIVE   SURGERY. 

and  urine  passed ;  was  relieved,  and  thought  much  better.  In  a 
few  days  became  delirious ;  pyaemia  well  developed ;  died  in  three 
days.  Post-mortem  showed  the  gland  entirely  suppurated  away. 
No  sign  of  either  lobe  of  prostate. 

We  believe  he  could  have  been  saved  if  we  had  performed  exter- 
nal perineal  urethrotomy  when  we  first  saw  him,  and  would  un- 
doubtedly treat  a  similar  case  in  this  way,  and  we  recommend  this 
course  in  all  similar  cases. 


A  New  Wire  Speculnm  for  the  Vagina  and  Rectum. 

In  the  summer  of  1870  I  was  called  to  see  Mr.  Charles  Bong,  a 
shoemaker,  of  Galveston,  Texas,  aged  about  fifty-four,  native  of 
Germany.  I  found  him  sufifering  from  fistula  in  ano,  of  fifteen 
years'  standing.  This  fistula  was  easily  probed  into  the  rectum, 
which  seemed  to  be  a  mass  of  ulcerations,  and  bled  freely  when  ex- 
amined by  the  finger  or  speculum.  The  whole  buttock  was  ulcer- 
ated for  nearly  three  inches  around  the  anus,  and  appeared  to  ooze 
out  a  sanious  serum  with  pus,  but  the  skin- was  not  broken,  nor  was 
there  any  other  fistula;  the  ulcer  was  in  folds;  even  to  the  furthest 
extent  it  had  effaced  the  skin.  He  had  a  fine  constitution,  and  was 
still  working  (at  times),  at  his  trade;  but  had  to  wear  cloths  under 
him  to  prevent  the  profuse  discharge  from  wetting  his  pants.  I 
ligated  the  fistula  in  the  ordinary  way,  being  afraid  to  use  the 
knife.  I  then  used  the  perchloride  of  iron  in  solution,  as  strong  as 
he  could  bear  it,  in  the  anus  and  outside,  where  there  was  such  a 
profuse  discharge. 

In  due  time  the  ligature  came  away,  and  the  fistula  was  closed, 
but  still  there  was  a  profuse  discharge,  and  the  oozing  out  of  serum 
and  pus  had  not  ceased,  though  the  perchloride  of  iron  had  been 
kept  up.  I  now  put  my  patient  under  chloroform,  and  incised 
the  sphincter,  and  applied  chloride  of  zinc,  forty  grains  to  one 
ounce  of  water,  over  its  entire  surface.  This  did  not  seem  to  act 
so  well  as  the  chloride  of  iron,  so  I  returned  to  it.  This  continued 
to  improve  him  and  to  lessen  the  discharge,  but  he  had  great  pain 
in  stooling,  and  there  appeared  to  be  a  considerable  contraction 
again  of  the  sphincter.  I  made  another  digital  examination,  and 
found  Httle  granular  lumps;  I  tried  every  variety  of  anal 
speculum  I  could  find,  but  none  would  give  me  any  satisfaction. 
I  took  a  pair  of  scissors  and  trimmed  off  all  the  little  granular 


NEW   SUEGICAL  INSTEUMENTS.  185 

bodies  I  could  reach ;  cut  off  all  the  external  folds,  down  through 

which  the  discharges  flowed;  applied  the  iron  again.     Under  this 

treatment  he  improved  and  became  much  bet-  ^^^  g2_ 

ter,  but  the  ulcer  did  not  seem  to  heal.     I  was 

anxious  to  get  a  full  view  of  the  ulcer,  and  one 

day  returning  to  my  ofl&ce,  I  saw  a  piece  of 

No.  6  wire,  and  it  at  once  struck  me  that  I 

could  bend  this  wire  so  as  to  accomplish  my 

object.     I   did  bend  it,  in  nearly  the  shape 

shown  in  Fig.  62.     This  gave  me  a  full  view 

of  the  entire  ulcer,  and  I  diagnosed  it  colloid        Wire  speculum. 

cancer,  and  putting  my  patient  under  chloroform,  I  applied  to  the 

entire  surface  (with  a  sponge  mop),  the  following : — 

R.    Acidi  chromici, 

AquaB  pluvialis,  aa    Sj. 

The  mop  was  saturated  with  this  solution,  and  every  part  being 
exposed  with  the  speculum,  I  made  the  apphcation  complete.  It 
turned  the  ulcerated  parts  a  whitish  color,  and  contracted  the  little 
gelatinous  cells  to  a  considerable  extent.  He  was  kept  under  chloro- 
form for  fifteen  minutes,  to  keep  off  the  pain,  when  the  ulcer  was 
washed  out  with  warm  water.  Patient  given  one-half  grain  dose  of 
morphine  as  soon  as  out  from  under  the  influence  of  the  chloroform. 
This  application  was  made  (under  chloroform)  every  week  for 
several  weeks,  and,  in  the  meantime,  patient  used  a  suppository  of 
sugar  of  lead,  morphine,  tannin,  and  extract  of  belladonna.     Thus— =■ 

B.    Plumbi  acetatis,  3j 

Tannin,  ^ss 

Extract  belladonnas, 

Morphise  sulphatis,  aa     gr.  xx. 

CerataB  simplicis  q.  s.  fiat  supposita  No.  xx. 
Sig. — One  every  night. 

He  continued  to  improve  under  this  treatment,  and  all  ulcera- 
tions around  the  anus,  externally,  ceased,  and  he  was  able  to  go  out 
to  church  and  about  town,  which  he  had  not  done  for  ten  years. 
He  was,  April,  1872,  quite  well,  except  a  contraction  of  the 
sphincter,  which  wiU  require  laceration,  as  it  produces  difficult  and 
painful  defecation. 

Having  had  such  good  success  with  this  speculum  in  the  anus, 
we  had  two  sizes  larger  made  for  the  vagina,  which  we  find,  for 
13 


186 


ORIGINAL   CONTRIBITTIONS   TO   OPERATIVE    SURCERY. 


ordinary  use,  better  than  any  speculum  we  have  ever  used.  When 
we  wish  to  examine  a  woman  with  Sims'  speculum,  we  insert  the 
handle  (A,  Fig.  63),  which  answers  every  purpose,  and  equally  as 


Fig.  63. 


Improved  Wire  Speculum  for  Vagina  and  Anus. 

well  as  Sims'.  In  a  few  cases,  we  have  found  the  vaginal  walls 
disposed  to  fall  in  between  the  tines  of  wire,  but  this  has  been 
remedied  by  wrapping  it  with  thread  or  gum  elastic  cords,  or  by 
a  double  bending  of  the  wire,  as  in  Figure  63,  J).  We  can  expand 
the  mouth  of  the  speculum  to  any  desired  extent,  by  getting  an 
assistant  to  hold  the  speculum  with  the  handle,  while  we  push  down 
the  end  marked  (C).     The  advantages  of  this  speculum  are : — 

1.  That  by  pressing  the  two  tines  of  wire  together,  it  is  easily 
introduced. 

2.  When  introduced,  the  tines  expand,  and  one  goes  to  the  right 
and  the  other  to  the  left  of  the  neck  of  the  womb,  fully  exposing 
the  OS  and  neck,  and  all  sides  of  the  vagina. 

3.  The  uterine  sound  can  be  used  with  the  speculum  in  place, 
without  the  guide  of  the  finger  or  a  tenaculum  to  pull  down  the  os. 

4.  Sponge  tents  can  be  inserted,  and  sponge  or  other  compresses 
made  to  the  mouth,  and  the  speculum  removed  without  disturbing 
them. 

5.  It  only  costs  two  dollars,  and  can  be  had  for  even  less,  while 
Sims'  costs  seven,  Bozeman's  twelve,  Knott's  eighteen,  Bivalve, 
Grerman  silver,  five. 


NEW   SURGICAL   INSTRUMENTS. 


187 


Fig.  64. 


I  am  using  in  my  vesico-vaginal  case  a  speculuiA  made  of  No.  8 
steel  wire,  galvanized,  shaped  exactly  like  Sims'  (Fig.  64),  and  it 
answers  my  purpose,  and  only  costs  $1.50. 
I  used  Davis'  tractor  before  I  invented 
these  specula,  in  two  cases  of  operation  for 
vesico-vaginal  fistula,  with  entire  success 
and  satisfaction  with  its  use. 

Messrs.  George  Tiemann  &  Co.,  67  Chat- 
ham  street,    New  York,   make  these   im- 
proved instruments,  of  three  sizes.     Two  for  the  vagina  and  one 
for  the  rectum.     All  of  my  instruments  can  be  had  of  this  firm. 


Wire  Speculum,  Sims' 
Patent. 


Fig.  65. 


B  — 


Ligation  of  Varicose  Teins  witli  a  Slinttle  Ifeedle,  Doul}lc  Spear-Pointed 

and  Straiglit. 

After  having  invented  the  needle  for  the  radical  cure  of  hernia, 
and  finding  it  to  work  so  well,  we  invented  the  needle  shown  in 
Fig.  65,  B.  It  is  straight,  about  four 
inches  long,  with  an  eye  in  each  end. 
It  is  threaded  with  silver  wire  at  one 
end,  and  the  threaded  end  is  then 
held  up  by  the  right  hand  of  the  ope- 
rator, and  steadying  the  vein  with 
the  left  hand  (the  vein  being  fully 
distended,  by  a  ligature  above,  to 
the  highest  point  of  dilatation),  the 
operator  puts  the  point  unthreaded 
directly  down  over  the  vein,  through 
the  skin,  into  the  cellular  tissue ; 
then  turning  it,  it  is  passed  under 
the  vein,  and  the  threaded  end  is 
then  seized  with  the  right  hand,  and 
pulled  on  until  the  unthreaded  end 
is  just  beyond  the  vein  ;  its  point  is 
then  elevated  above  the  vein,  and  Ligating  varicose  veins, 

pushed  out  where  it  was  first  started,  throwing  a  ligature  entirely 
around  the  vein,  without  inclosing  anything  but  the  coats;  the 
ends  of  the  wire  are  then  twisted,  or  tied  over  a  bougie,  which  is 
better,  as  they  can  be  taken  out  more  easily  than  when  twisted, 
and  the  bougie  helps  to  compress  the  vein,  until  the  vein  is  com- 
pletely closed.     I  have  used  a  roll  of  adhesive  plaster  in  place  of 


188  ORIGINAL   CONTRIBUTIONS   TO    OPERATIVE   SURGERY. 

the  bougie.  "We  continue  to  put  in  ligature  after  ligature,  down- 
ward, until  all  the  varicose  veins  are  strangulated ;  the  limb  is  then 
put  up  in  a  roller-bandage,  and  wires  left  in  until  they  begin  to 
suppurate  when  the  wires  are  untwisted  and  taken  out. 

The  first  case  we  used  this  needle  in  was  a  very  bad  one,  com- 
plicated with  a  large  varicose  ulcer ;  and  before  the  ligatures  were 
taken  out  the  ulcer  had  nearly  healed  up,  and  looked  perfectly 
healthy,  having  lost  all  of  its  livid  and  indurated  character.  I 
now  apply  this  method  to  the  cure  of  varicocele,  and  I  always 
ligate  in  varicose  ulcers  before  attempting  any  other  treatment.  So 
far  I  have  had  no  unfavorable  results,  and  but  little  pain  or  suppu- 
ration. 

REPORT   OF  CASES. 

Case  1. — Irish  sailor;  varicose  veins  in  both  legs,  as  seen  in  Fig. 
65,  from  which  the  cut  was  drawn.  He  had  a  large  ulcer  over  the 
whole  of  the  outer  side  of  leg,  for  which  he  was  admitted  to  the 
City  Hospital,  1867.  I  ligated  the  varicose  veins  on  that  side,  by 
the  needle  described,  commencing  at  the  highest  enlargement  and 
coming  down,  and  not  as  in  figure,  from  below  upward,  which  is 
an  error  of  the  artist.  To  begin  above  causes  the  vein  to  swell, 
and  to  begin  below  prevents  the  operator  from  seeing  and  feeling 
the  vein.  In  this  case,  the  first  operated  on,  I  twisted  the  wires, 
but  found  them  difficult  to  remove,  for  in  untwisting  them  I 
twisted  the  wire  too  far,  and  it  would  not  come  out.  After  having 
tied  all  the  ligatures  necessary,  we  surrounded  the  leg,  from  the 
foot  to  the  perineum,  with  a  roller  bandage,  putting  lint  over  the 
ulcer,  and  left  it  so  for  eight  days.  On  removing  the  bandage  we 
found  the  ulcer  healthy,  and  nearly  healed  up ;  all  lividity  had  left 
it.  We  took  out  the  wires  and  reapplied  the  bandage.  In  two 
more  weeks  the  ulcer  was  perfectly  well,  and  the  varicose  veins 
gone.  The  other  leg  was  then  operated  on  in  the  same  way,  with 
same  results.  Patient  was  discharged,  cured.  Four  years  after- 
ward he  came  to  see  me  at  my  office,  still  perfectly  well. 

Case  2.— Mr.  E.  L.  B.,  Jonesville,  Texas,  April  20th,  1876, 
aged  48,  called  me  to  see  him;  found  him  with  two  varicose  ulcers 
on  left  leg,  of  seventeen  years'  standing;  suffered  from  chills  and 
fever  when  it  first  broke  out;  was  dropsical  and  had  an  enlarged 
spleen.  Patient  at  present  healthy,  except  the  ulcers  and  varicosed 
veins.     Not  having  my  straight  needle  with  me,  I  operated  on  him 


NEW   SUEGICAL   INSTRUMENTS.  189 

with  my  hernia  needle,  putting  in  nine  sutures,  using  a  roll  of 
adhesive  plaster  in  place  of  the  bougie,  and  tying  the  wires  instead 
of  twisting  them.  Put  lint  saturated  with  chloride  of  zinc  solu- 
tion, two  grains  to  ounce  of  water,  over  the  ulcer,  and  applied  over 
this  a  roller  bandage  from  foot  to  thigh.  After  he  came  out  from 
under  the  chloroform,  gave  him  half-grain  doses  of  morphine,  to 
keep  him  easy. 

April  22d.  Removed  dressing  of  rollers  and  lint,  washed  the 
leg  and  applied  a  solution  of  nitrate  of  silver,  twenty  grains  to  the 
ounce,  along  the  line  of  and  over  the  ulcers ;  re-applied  roller.  Leg 
not  much  swollen  and  ulcers  more  healthy.  April  25th,  stitches 
partly  taken  out;  patient  doing  well;  redress  as  before;  did  not 
see  him  again  until  the  25th  of  May,  owing  to  a  spell  of  sickness. 
Found  Mr.  .B.  walking  about ;  had  been  plowing ;  leg  much  swollen ; 
took  out  all  the  old  ligatures  on  the  26th;  put  two  more  new  liga- 
tures in.  May  28th,  redressed  the  leg;  ulcers  better;  veins  oblite- 
rated; dressed  leg  with  adhesive  strips  over  ulcer,  nitrate  of  silver 
wash,  and  roller  bandage.  Have  not  seen  him  since;  sent  him  an 
elastic  stocking.  When  last  heard  from  ulcer  healed  up,  Mr.  B 
traveling  out 'West.     I  prescribed  for  him 

R.     Iodide  of  potash,  ^vj 

Aquae,  qt.j 

Hyd.  chlo.  corrosivi,  gr.j.  M. 

Sig.    Tablespoonful  three  times  a  day. 

R.     Tine,  cinchonse, 
Tine,  colum  bonis, 

Tine,  gentianae,  M.     ^ij.  M. 

Sig.  Tablespoonful  every  two  hours  each  day,  until  four  doses  were  taken 
every  five  days. 

This  patient  did  not  follow  directions  while  I  was  sick,  or  he 
would  have  recovered  sooner.  It  is  next  to  impossible  to  cure  an 
old  ulcer  without  rest,  and  I  have  been  unable  to  cure  varicose 
ulcers  without  ligating  the  veins,  or  putting  on  elastic  stockings,  as 
seen  in  Fig.  38,  page  115,  J,  K,  L,  M,  K 

Dislocation  of  tlie  Humeras  at  tlie  Slioalder  Joint  (Scapulo-Humeral). 

Scapulo-humeral  dislocations  are  divided  by  recent  writers  into 
two  varieties. 

1.  In  front  of  middle  of  glenoid  cavity. 

2.  Behind  the  middle  of  glenoid,  cavity. 


190  ORIGINAL   CONTEIBUTIONS   TO   OPERATIVE   SURGERY. 

r  1.  Extra-coracoid. 

^r  T      1       •  T    !  2.  Sub-coracoid. 
I.  Medio-fflenoid.  ^  o    t  .  ■  ^ 

°  !  6.  intra-coracoid. 

[  4.  Sub-clavicular. 

II.  Sub-glenoid.     j  I'  ^^^P^^^- 
^  I  2.  Costal. 

_  III.  Super-glenoid. 

n  f  1.  Sub-acromion. 

I  2.  Sub-spinous. 

Professor  Gross  divides  them  into  three. 

1.  Axillary — into  the  axillary  space. 

2.  Thoracic  -  on  the  chest, 

3.  Sub-spinous. 

No  doubt  there  are  nine  positions  the  head  of  the  humerus  can 
take  in  reference  to  the  centre  of  the  glenoid  cavity. 

Anterior  and  Fosterior. 

1.  Outer  side  of  coracoid  process. 

2.  Under  coracoid  process. 

3.  Inside  of  coracoid  process. 

4.  Sub-clavicular. 

5.  Costal — on  the  ribs. 

1.  Sub-acromion — under  acromion  process. 

2.  Sub-spinous — under  the  spine  of  scapula. 

3.  Sub-scapularis — under  the  edge  of  scapula. 

The  division  into  anterior  and  posterior  is  important  in  reference 
to  the  position  of  the  elbow-joint.  In  the  anterior  varieties 
the  elbow  lies  outside  of  a  straight  line  drawn  from  the  centre  of  the 
glenoid  cavity  to  the  anterior  superior  spine  of  the  ilium;  and  vice 
versa,  when  the  head  is  in  the  posterior  position,  the  elbow  is  in 
front,  or  on  that  line. 

Fig.  66,  page  191,  represents  the  arm  in  its  natural  position,  with 
the  hand  resting  over  the  right  shoulder,  with  the  elbow  touching 
the  chest. 

According  to  Dugas,  this  position  cannot  be  obtained  voluntarily 
by  the  patient,  or  forcibly  by  the  surgeon,  in  any  of  the  disloca- 
tions at  the  scapulo-humeral  articulation,  provided  the  body  is  kept 
straight  and  the  shoulders  level. 

Fig.  67,  page  191,  shows  the  head  of  the  humerus  between  the 


NEW   SUEGICAL   INST.1UMENT3. 


191 


two  heads  of  the  biceps  mus- 
cle, and  resting  against  the 
clavicle,  and  posterior  and 
superior  to  the  coracoid  pro- 
cess, and  above  its  coraco- 
clavicular  ligament.  The 
arm  is  thrown  back  and 
pressed  to  the  ribs,  being 
the  medio-gleno  sub-clavic- 
ular position. 

This  dislocation  is  very- 
difficult  to  reduce  by  any  of 
the  usual  means,  such  as 
heel  in  axilla,  knee  in  axilla, 
extension  by  bandages 
around  arm  and  under  and 
in  arm  pit,  or  by  manipula- 
tions as  shown  in  most  of 
our  text-books.  I  have 
seen  four  cases  of  this  dis- 
location that  defied  all  the 
usual  means,  three  of  which 
were  reduced  by  the  pro- 
cess shown  in  Fig.  68. 

Report  of  Cases. 

Case  1. — An  Irish  sailor 
in  City  Hospital,  Galveston, 
1866 ;  dislocation  sub-clavi- 
cular extra-coracoid.  I 
tried  the  heel  in  axilla,  with 
powerful  extension  by  assist- 
ants, until  my  foot  became 
numb  and  I  was  forced  to  re- 
move it.  I  then  got  the  roll- 
ing pin  out  of  the  kitchen, 
and  held  this  under  the 
axilla  while  powerful  exten- 
sion was  made;  still  failed. 

Seeing  the  bone  was  held 


Fig.  6 : 


Fig  67 


192         ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE  SURGERY. 

in  its  position  by  the  two  heads  of  the  biceps,  the  pectoralis  major, 
latissimus  dorsi  and  teres  major  locking  the  head  of  the  humerus 
pje_(;s_  between  the  coracoid  pro- 

cess and  clavicle  and  on  the 
coraco-clavicular  ligament, 
I  proposed  to  elevate  it  from 
its  fixed  position  by  a  por- 
ter bottle,  which  would  roll, 
and  not  be  so  fixed  as  the 
rolling  pin.  I  procured  the 
bottle  and  placed  it  in  the  po- 
sition seen  in  Fig.  68,  hold- 
ing it  by  the  neck  with  the 
left  hand,  and  with  the  right 
making  extension  back- 
ward, outward,  and  down- 
ward. By  so  doing  I  raised 
the  head  out  of  its  imbedded 
position.  Then  the  latissi- 
mus dorsi,  pectoralis  major, 
and  teres  major  assisted  me 
in  pulling  it  in  position,  the 
bottle  rolling  to  let  the  head  come  down. 

Case  2. — While  in  Philadelphia,  in  1872,  I  saw  a  case  of  this 
dislocation  in  Prof.  G's  clinic,  and  he  tried  all  the  usual  means  for 
its  reduction  and  failed,  but  remarked,  before  he  begun,  that  all 
surgeons  had  failed  in  some  of  the  dislocations,  and  if  he  failed  he 
would  not  feel  ashamed,  as  Dr.  L.  had  failed  on  this  man  at  the 
hospital.  Dr.  P.,  of  Illinois,  was  present,  a  stout,  strong  man. 
He  tried  to  reduce  it  with  two  sheets,  and  also  failed. 

I  remarked  to  Prof.  Gr.  that  I  had  seen  a  similar  case,  and 
reduced  it  at  last  with  a  porter  bottle  in  the  axilla,  after  failing 
with  all  other  means,  which  he  reported  to  his  class,  remarking  he 
was  too  much  exhausted  to  try  it,  and  I  was  so  feeble  I  could  not. 

Case  3. — Emigrant,  at  Austin,  Texas,  January,  1873.  Was 
called  to  see  this  case,  by  Drs.  M.  and  L.  of  that  city.  They  had 
tried  all  the  usual  means  and  had  failed.  I  told  them  of  the  cases 
reported  above,  and  that  I  would  try  the  porter-bottle  again  if 
they  would  put  the  patient  under  chloroform,  which  was  done,  and 


NEW  SURGICAL   INSTEUMENTS. 


193 


without  the  least  trouble  I  reduced  it,  as  described  in  case  1, 
February  3d. 

Case  4. — "White  woman.  Galveston,  Texas,  December,  1875. 
I  was  called  to  see  this  case  by  Professor  R.,  and  Demonstrator  S., 
of  the  Texas  Medical  College  and  Hospital.  They  had  tried  all 
the  usual  means  under  chloroform,  and  had  produced,  on  the  hands 
and  under  the  arms,  abrasions,  by  the  powerful  extension  they  had 
made,  but  had  failed.  I  made  a  clinic  of  this  case,  and  reduced  it 
in  the  presence  of  the  class  and  professors  Rankin,  Burroughs  and 
Dr.  Sunburg,  without  the  least  trouble.  Professor  Burroughs  was 
a  student  at  the  time  I  reduced  the  first  case,  and  assisted  in  its 
reduction. 

All  the  other  varieties  of  dislocation  at  the  scapulo-humeral 
articulation  are  easy  to  reduce  by  any  of  the  usual  means,  but  I 
have  found  the  latter  better  than  the  heel  and  knee  holding  it, 
while  assistants  make  extension  and  counter-extension. 

Before  closing  this  article,  I  wish  to  say  more  about  Dugas' 
pathognomonic  sign  of  dislocations  of  the  shoulder,  as  some  cases 
are  very  hard  to  diagnose,  such  as  contusions  of  the  deltoid,  frac- 
tures in  the  neck  of  the  humerus,  and  lacerations  of  the  long  head 
of  the  biceps.  In  all  these  cases  the  arm  can  be  brought  into  the 
position  as  seen  in  Fig.  66.  This  is  impossible  in  all  dislocations, 
but  can  be  done  in  all  fractures  and  lacerations  or  contusions. 

A  New  Method  for  the  Bednction  of  the  Phalanges  of  the  Hand 

and  Foot. 

In  October,  1856,  I  had  the  misfortune  to  get  my  left  second 
finger  dislocated,  by  attempting  to  hold  a  man  by  his  coat  collar, 
and  it  was  twisted  almost  to  a  right  angle  (see  Fig.  69).     Knowing 

Fig.  69. 


Mode  of  Reducing  Dislocated  Phalanx. 


how  difficult  these  dislocations  are  to  reduce,  I  felt  considerable 
uneasiness  about  my  case.     But  after  examining  it  for  a  while,  I 


194 


OEIGINAL   CONTEIBUTIONS   TO   OPERATIVE   SURGERY. 


Fig.  70. 


thouglit  I  could  reduce  it  by  manipulation,  in  the  following  simple 
manner : — Taking  hold  of  the  point  of  my  finger  with  my  right 
hand,  I  gave  it  a  slight  extension,  and  at  the  same  time  twisted  it 
down  on  itself,  until  I  made  the  two  corners  of  the  distal  and 
proximal  bones  of  the  finger  catch,  one  against  the  other,  and 
still  keeping  the  point  in  a  twist,  I  gradu- 
ally pulled  it  straight,  reducing  it  without 
the  least  trouble.  Fig.  69  represents  the 
manner  in  which  the  finger  was  taken  hold 
of,  and  shows  the  twisting  motion.  Fig. 
70  shows  the  position  of  the  dislocated 
bones.  Levis'  splint  may  be  used,  to  give 
greater  extension,  but  I  think  this  will 
second  Phalanx  Dislocated.  ^^^^^^  ^^   ^^^^^  Unnecessary.     Bending 

"the  bone  at  a  right  angle,  and  then  pushing  the  head  of  the 
distal  point  down,"  will,  I  apprehend,  be  found  much  more  difficult, 
but  this  is  now  deemed  the  best  of  all  methods. 


Fig.  71. 


A  ITew  Diagnostic  Symptom  of  Dislocation  of  the  Head  of  the  Radius, 
Without  Fracture  of  the  Ulna. 

Mrs.  "W.  E.  H.,  in  Panola  county,  Miss.,  A.  D.  1850,  was  run- 
ning from  the  house  to  the  kitchen,  and  fell,  catching  on  her  hand, 

and  twisting  her  arm  outward ; 
the  head  of  the  radius  was 
thrown  out  of  its  natural  place, 
rupturing  the  annular  liga- 
ment, the  biceps  muscle  pulling 
it  up,  lodging  it  above  the  cli- 
noid  fossa  of  the  humerus,  as 
seen  in  Fig.  71.  She  immedi- 
ately sent  for  Dr.  McMullin, 
who  came  and  examined  it,  and 
pronounced  it  a  contusion,  and 
not  a  fracture  or  dislocation. 
It  got  no  better,  and  about  the 
tenth  day  I  was  sent  for,  and  found  the  arm  still  much  swollen  and 
livid.  There  was  complete  pronation,  supination,  and  flexion  to  a 
remarkable  degree.  The  parts  were  so  much  swollen  I  could  not 
feel  the  head  of  the  bone  in  its  abnormal  position,  so  I  pronounced 
it  a  contusion.     The  patient  did  not  get  any  better  for  a  long  time. 


Head  of  Radius  in  Clinoid  Fossa, 


NEW  SURGICAL   INSTRUMENTS.  195 

So,  finally,  Mr.  H.  took  her  to  Memphis,  and  the  doctor  there  pro- 
nounced it  a  fracture  and  dislocation,  but  did  not  resort  to  any 
means  of  reduction.  He  brought  her  back  to  me,  and  immediately 
upon  seeing  the  arm,  after  the  swelling  had  gone  down,  I  discovered 
the  head  of  the  radius  in  its  abnormal  position ;  the  lady  could 
not  flex  her  arm  so  as  to  comb  her  hair  or  feed  herself.  This  is  the 
PATHOGNOMONIC  SYMPTOM.  The  arm  cannot  be  flexed.  Patient 
cannot  touch  the  nose. 

We  m^ade  some  ineflfectual  efforts  to  reduce  it,  but  failed. 

Mr.  Brise  Collins,  Memphis,  Tennessee,  was,  in  the  spring  of 
1852,  thrown  from  his  horse,  catching  on  his  hand,  and  producing 
exactly  the  same  dislocation  as  that  of  Mrs.  H. ;  he  came  to  me 
with  it  still  unreduced.  Eemembering  the  above  case,  I  immediately 
diagnosed  it  as  a  case  of  dislocation  of  the  head  of  the  radius, 
and  as  quickly  reduced  it  by  getting  my  brother,  Dr.  Alep.  Dowell, 
to  make  extension,  and  to  twist  the  head  outward,  completely 
supinating  it,  while  I,  with  ray  thumb  and  fingers,  pressed  the 
head  back  in  its  place,  flexed  the  arm,  and  put  it  into  a  sling,  and 
kept  it  in  a  sling  for  six  weeks,  when  it  was  completely  united,  and 
remained  reduced  as  long  as  I  knew  him.  ^ 

In  1870,  a  little  boy,  twelve  years  old,  was  brought  to  me  with 
an  old  dislocation,  that  had  been  set  with  the  arm  extended,  and 
kept  in  that  position  for  a  month.  The  ulna  and  radius  had  been 
dislocated,  with  a  fracture  of  the  clinoid  process,  and  the  radius 
was  lying  in  the  clinoid  cavity  of  the  humerus.  He  could  pronate 
and  supinate  his  hand,  but  could  not  comb  his  head  or  feed  himself, 
as  his  arm  would  be  pushed  off  by  the  head  of  the  radius  pressing 
against  the  anterior  surface  of  the  humerus.  I  reduced  it  by  twist- 
ing and  flexing  the  arm  around  my  knee  and  over  it,  until  he  could 
touch  his  nose  and  comb  his  head.  I  put  his  arm  into  a  sling,  but 
it  did  not  retain  it,  so  I  applied  angular  splints  and  bandaged  it  in 
a  flexed  condition,  and  kept  it  so  for  a  short  time.  As  he  was  un- 
ruly, and  would  take  the  bandage  off,  I  had  to  set  it  several  times ; 
but  it  never  became  firmly  united  at  the  annular  ligament,  and  he 
could  not  use  it  well  in  combing  or  feeding  himself,  yet  was  greatly 
improved. 

Remarks. — At  the  time  I  saw  my  first  case,  the  accident  was 
scarcely  mentioned  in  works  on  surgery,  and  it  was  presumed  to  be 
barely  possible  for  the  radius  to  be  dislocated  anteriorly  without 
fracture  of  the  ulna;  there  were  no  diagnostic  symptoms  given. 


196  ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 

These  cases  have  convinced  me  that,  at  the  time  of  dislocation, 
inability  to  flex  the  arm  to  the  head  can  only  be  relied  on  as  a 
diagnostic  sign,  as  the  swelling  obscures  the  position  of  the 
head  of  the  radius.  It  is  easily  seen  that  this  dislocation  could  not 
take  place  in  any  other  way  than  by  twisting  the  forearm,  as  de- 
scribed in  the  two  cases  given  above,  where  there  was  no  fracture 
owing  to  the  interosseus  ligament,  which  will  not  admit  of  its  being 
separated  in  any  other  way.  In  the  last  case  there  was  a  fracture 
of  the  clinoid  process  of  the  radius,  and  the  ulna  was  pressed  back- 
ward, while  the  radius  was  pressed  upward  anteriorly  on  the 
humerus.  Extension  and  pressure  reduced  it,  but  I  could  not  get 
union  of  the  annular  ligament  or  clinoid  process ;  hence  its  partial 
return. 

Arrow  and  Bullet  Extractor. 

In  studying  arrow  wounds,  I  found  there  was  not  in  any  sur- 
gery I  could  find  a  good  and  efficient  arrow  extractor.     Surgeon 
Bill's  was  believed  to  be  the  best,  but  it  was  to  my  eyes  impracti- 
cable and  unscientific.     So,  with  a  few  hours'  thought  I  produced 
Pig.  72,  Qj^Q^  represented  by  Fig.  72.     It 

is  from  six  to  eight  inches  long, 
-^mgry^^  or  a  little  longer  than  an  ordinary 
Arrow  Extractor.  bullet  forceps,  and  the  blades  are 

made  flat  and  cross  each  other,  so  as  to  be  only  of  the  same  width  of 
the  full  opening  of  its  claws.  The  claws  are  made  hollow  in  the 
inner  side  and  serrated ;  the  outer  edge  is  made  sharp,  like  a  per- 
forator, and  the  points  are  made  sharp  and  cutting.  The'  forceps 
closed,  the  two  jaws  come  together,  and  the  handles  are  touching 
each  other.  The  forceps  thus  closed  are  inserted  into  the  arrow 
wound,  and  pushed  down  like  a  bullet  forceps  until  the  head  of  the 
arrow  is  struck,  and  then  the  blades  are  opened  their  fullest  extent, 
and  pushed  down  over  the  arrow,  as  seen  in  the  figure.  With  this 
forceps,  it  will  be  easier  to  remove  an  arrow  than  a  bullet.  This, 
though  lately  brought  out,  will  prove  a  valuable  instrument  to 
the  United  States  Surgeon,  especially  at  this  time,  as  it  is  a  very 
difficult  operation  to  remove  an  arrow-head,  frequently  requiring 
a  deep  incision.  One-third  of  the  inhabitants  of  the  globe  use 
arrows,  and  every  surgeon  on  our  western  prairies  should  have  one 
of  these  instruments  in  his  case.     I  commend  this  forceps  to  the 


NEW   SURGICAL   INSTRUMENTS.  197 

western  surgeons,  and  the  United  States  Army  Surgeon  in  Indian 
districts,  for  the  extraction  of  arrows  and  bullets. 

EXTRACTION    OF    AN  ARROW   HEAD    FROM    THE    FEMUR    AFTER    SIX 
YEARS   AND   EIGHT   MONTHS'  RETENTION. 

"William  Miller,  aged  35,  from  McCulloch  county,  Texas,  consulted 
me,  in  1873,  for  running  sores  on  his  thigh,  which  he  said  were  from 
a  wound  from  an  Indian  arrow,  received  over  six  years  before,  in  an 
Indian  fight  at  Bee  Creek,  San  Saba  county.  He  was  shot  twenty- 
seven  times.  He  pulled  out  all  the  arrows  during  the  fight,  except 
six.  One  cut  the  side  of  the  face,  and  an  artery,  from  which  he 
bled  for  several  weeks,  and  was  only  stopped  at  last,  by  a  powder 
of  dry  horse  dung  put  on  by  his  brother.  Three  arrows  had  their 
heads  pulled  ofi",  and  ulcerated  out,  which  his  father  gave  me. 
One  entered  his  back,  and  he  thinks  it  is  still  there ;  one  struck  him 
in  the  thigh,  where  the  discharging  holes  were.  With  this  statement 
I  believed  the  femur  was  fractured  by  the  arrow,  and  that  there 
was  a  piece  of  caries  of  bone  that  kept  up  the  discharge.  So  I 
proposed  to  turn  up  a  flap  from  both  holes  and  chisel  it  out,  to 
which  he  consented.  We  then  put  him  under  chloroform,  incised 
a  V-shaped  flap,  and  found  the  bone  ulcerated,  and  under  a  shelf  of 
the  bone  we  struck  an  arrow  head  bent  on  itself,  the  point  sticking 
into  the  body  of  the  femur,  and  the  body  bent  down  on  the  bone,  and 
a  shelf  of  bone  covering  it.  I  tried  to  pull  it  out  with  a  dressing 
forceps,  but  could  not.  I  then  took  a  chisel  I  had  ready,  to  pare 
the  bone  and  pried  it  up  loose,  breaking  off  one  corner  of  the 
chisel.  I  then  pulled  it  out,  finding  it  bent  almost  at  right  angles. 
The  wound  was  closed,  leaving  the  piece  of  chisel  in.  It  healed 
up  finally,  the  piece  of  chisel  came  out,  and  he  wrote  me  from 
Kansas  that  his  leg  was  entirely  well  but  he  had  a  bad  cough 
after  it  healed  up.  He  was  very  stout  and  healthy;  had  no  ten- 
dency to  consumption,  and  I  presumed  he  had  taken  cold  from 
being  up  in  that  climate.  I  sent  him  a  cough  mixture,  and  have 
not  heard  from  him  since.  I  presume  he  is  quite  well,  or  I  should 
have  heard  from  him. 

Osteo-Fibroid  Tamor  of  Inferior  Maxillary  Bone— Excision— Cure. 

Jacob  Yancy,  aged  fifty-three,  colored;  laborer;  stout  built; 
in  good  health.  Fifteen  years  before  he  had  a  blow  on  the 
chin  from   the  rebound  of  an  ox   bow,  which   he  was  bending. 


198 


ORIGINAL   CONTRIBUTIONS   TO    OPERATIVE   SURGERY. 


Jacob  Yancy,  Osteo-flbroid  Tumor,  removed^ 
12thof  April,  1876. 


From   this   a    tumor    commenced    to   grow.      It  is    now,   April 
12th,  1876,  as   large  as  a  child's   head.     An   exact   picture   of 
it  is  given  in  the  engraving,  taken  from  a  photograph  before  the 
Fig.  73.  Operation.     We  proposed  to 

remove  it  by  excision,  and  on 
the  12th  of  April,  assisted 
by  Drs.  Orman  Knox,  W.  W. 
Perry,  and  S.  F.  Vaughn, 
we  excised  it  (patient  being 
under  chloroform,  and  neck 
over  tumor  shaved)  in  the 
following  manner ;  an  inci- 
sion was  made  from  the  angle 
at  the  clinoid  process  of  the 
inferior  maxillary,  under  the 
tumor,  to  the  opposite  side 
and  angle,  being  twelve  inches 
long ;  from  this  another  in- 
cision was  made  above  the 
tumor,  one  inch  from  the  in- 
ferior lip,  across  to  the  other  angle,  being  seven  inches  in  length. 
The  lip  or  flap  was  then  dissected  up  from  the  bone;  the  tongue  cut 
loose  from  its  attachments  to  the  inferior  maxillary,  cutting  in  two 
the  genio-hyoglossus  muscles,  turning  up  the  tongue  and  carefully 
separating  it  from  the  inferior  maxillary;  a  ligature  was  now  put 
through  the  inferior  part  of  the  tongue,  and  the  tongue  pulled  out 
and  held  out  of  the  way.  The  inferior  maxillary  was  then  sawed  in 
two  at  each  angle,  and  the  tumor  pressed  down  and  dissected  from 
the  inferior  flap  and  entirely  removed.  Two  teeth  were  left  in  one 
side,  the  other  had  none.  Several  small  arteries  were  twisted,  but 
none  required  to  be  tied ;  two  were  tied  on  the  tumor  while  it  was 
being  removed,  as  it  bled  profusely  while  the  incisions  were  being 
made.  Several  veins  were  compressed ;  about  three  pints  of  blood 
were  lost.  The  incisions  were  then  closed  with  interrupted 
sutures.  The  tongue  when  let  loose  fell  back,  and  would  have 
suffocated  the  patient,  but  it  was  firmly  secured  by  ligature  to  the 
lower  flap,  so  it  could  not  fall  back,  also  to  secure  adhesions  to  the 
base  of  the  tongue  where  it  was  dissected  from  the  tumor.  Patient 
came  well  out  from  the  chloroform,  and  was  able  to  speak  in  two 
and  a  half  hours  from  the  commencement  of  the  administration  of 


NEW   SUEGICAL   INSTEUMENTS.  199 

the  chloroform.  The  mouth  was  then  washed  out  by  means  of  an 
elastic  tube,  one  end  in  a  basin  and  the  other  held  in  the  month, 
the  head  bent  to  let  it  run  out.  Half  grain  doses  of  morphine  and 
a  little  toddy  of  whisky  were  given.  Pulse  feeble,  but  regular. 
April  13th.  Patient  doing  well ;  pulse  good ;  drinks  milk,  coffee 
and  water,  through  the  tube,  used  as  a  syphon.  April  16th.  Dr. 
Knox  took  out  some  stitches.  April  17th.  I  removed  all  the 
stitches  on  the  fifth  day  after  operation ;  dressed  with  adhesive 
strips  and  collodion ;  washed  out  his  mouth  with  chloride  of  zinc, 
one  and  a  half  grains  to  one  ounce  of  water.  This  was  directed  to 
be  done  often,  and  always  before  taking  water  or  milk.  Patient 
well  and  cheerful ;  complete  reaction  but  no  fever ;  bowels  moved 
with  enemas;  incision  united  so  firm  as  to  hold  well  when  the 
stitches  were  taken  out.  Ligature  holding  the  tongue  taken  out 
on  the  fifteenth  day ;  one  or  two  sutures  unseen  were  removed  on 
the  thirtieth  day.  Patient  was  out  in  his  field,  hoeing  cotton,  on 
the  twenty-sixth  day  after  the  operation.  Talks  plainer  than  before 
the  operation.  Feeds  himself  with  the  elastic  tube,  with  milk 
and  coffee ;  eats  mush  and  soup.  Came  to  see  me  on  the  26th  of 
May ;  looks  nearly  as  stout  and  healthy  as  before  the  operation. 
Tumor  was  composed  of  osseous  cells,  filled  with  clear  serum  in 
some,  yellowish  serum  in  others,  and  one  very  large,  of  dark  bloody 
matter,  the  color  and  thickness  of  molasses.  Preparation  in  Texas 
Medical  College. 

Fibroid  Tumor  of  Tliigli,  left  Side,  Large  as  a  Cocoanut— Excision— Cure. 

May  30th,  1876,  was  called  to  see  Mr.  C.  F.  Johnson,  aged  forty- 
three,  native  of  Alabama,  school  teacher;  fine  constitution;  wheel- 
wright by  profession.  Has  a  large  tumor,  about  the  size  of  a 
cocoanut,  immediately  over  the  femoral  artery,  about  the  bifurcation 
of  the  superior  profunda  artery.  In  1859  it  began  to  grow ;  was 
not  larger  than  a  shot  when  first  perceived ;  has  been  growing  for 
seventeen  years,  but  lately  has  grown  faster,  and  is  now  so  large  he 
cannot  get  on  horseback  without  lifting  it  out  of  the  way.  No 
known  cause  of  its  growth ;  supposed  to  be  from  the  kick  of  a  horse, 
but  really  does  not  know  that  it  had  anything  to  do  with  it.  Was 
supposed  to  be  connected  with  the  thigh  bone,  and  to  involve  the 
artery,  by  physicians  that  had  examined  it.  Upon  a  close  examina- 
tion we  believed  it  to  be  a  fibroid  tumor,  and  not  connected  with  the 
bone;  so  we  proposed  to  remove  it  by  excision.     Patient  being 


200         ORIGINAL   CONTRIBUTIONS   TO   OPERATIVE   SURGERY. 

cUoroformed  by  Dr.  Knox,  of  Jonesville,  we  made  a  straight  in- 
cision, eight  inches  long,  over  the  tumor,  avoiding  the  veins.  There 
were  several  very  large  ones  over  the  tumor,  and  the  femoral  nerve, 
which  was  plainly  seen  in  the  dissection,  as  large  as  a  goose  quill, 
was  on  its  outer  side. 

The  attachments  were  torn  loose  with  the  fingers  and  the  handle 
of  the  scalpel,  and  the  tumor  removed  without  the  loss  of  two  ounces 
of  blood.  Tumor,  when  removed,  weighed  three  pounds  and  a  half. 
Wound  was  closed,  without  tying  an  artery,  with  silver  sutures,  and 
adhesive  plasters  covered  with  lint  and  collodion.  After  patient 
came  out  from  under  chloroform,  was  given  a  dose  of  morphine. 
Dressing  left  to  eighth  day ;  incision  partially  closed,  but  suppura- 
tion occurred  in  the  centre ;  part  washed  out,  and  dressed  with  ad- 
hesive strips ;  patient  well  in  three  weeks. 

Specimen  in  Texas  Medical  College ;  was  not  opened.  Patient 
returned  to  his  duties  in  thirty  days.  These  two  cases  had  been 
examined  by  several  surgeons  who  pronounced  them  incapable  of 
removal,  assuming  that  if  it  was  attempted  immediate  death  from 
hemorrhage  would  likely  be  the  result.  We  have  no  apprehension 
of  the  return  of  either. 


INDEX. 


Page 

Abdominal  hernia , 9 

Abdominal  hernia,  classification  of. 12 

Age  as  a  predisposing  cause  of  hernia 21 

Anatomy  of  hernia , 23 

Angeio-mesenteriocele 16 

Ascites  as  a  predisposing  cause  of  hernia 21 

Baron  Suiten's  method  of  reducing  hernia 78-97 

Burns  as  a  predisposing  cause  of  hernia 21 

Cause  of  irreducible  hernia. 70 

Causes,  predisposing,  exciting,  and  inciting,  of  hernia 21 

Causes  producing  hernia 16 

Complete  hernia , 12 

Compound  contents  of  hernia , 20 

Congenital  hernia 12 

Coverings  of  hernia 9-23 

Coverings  of  femoral  hernia , , 107 

Diagnosis  of  irreducible  tumors ....•  92 

Diagnosis  of  reducible  tumors 91 

Diaphragmatic  hernia 14-120 

Direct  hernia 12 

Diverticular  hernia - 16-121 

Encysted  hernia 16-89 

Enterocele.... , , ^ 16 

Entero-epiplocele 16 

Enteronal  hernia - 14-121 

Epigastric  hernia • 14-119 

Exciting  causes  of  hernia 21 

Femoral  hernia 14-105 

Funiculated  hernia 88 

Gastrocele , j^ 16 

Hernia •• 9 

Hernia  abdominalis 9 

Hernia  abdominalis,  classification  of 12 

Hernia  abdominalis,  general  causes  of. 10 

Hernia  abdominalis,  general  symptoms  of. 10 

13  201 


202  INDEX. 

PAGE 

Hernia  abdominalis,  special  symptoms  of. 10 

Hernia  abdominalis,  treatment  of. 26,  70,  75,  76,  77,  78,  108 

Hernia,  anatomy  of.. 23 

Hernia,  character  and  relations  of 94 

Hernia,  cerebri 9 

Hernia,  complete 12 

Hernia,  congenital 12 

Hernia,  coverings  of. 9,  23-107 

Hernia,  crural 14-107 

Hernia,  diaphragmatic 14-120 

Hernia,  direct 12 

Hernia,  diverticular 16-121 

Hernia,  dycotal  table  of. 18 

Hernia,  encysted 16-89 

Hernia,  enteronal 14-121 

Hernia,  epigastric 14-119 

Hernia,  exciting  causes  of 21 

Hernia,  femoral 14-105 

Hernia,  femoral,  coverings  of. 107 

Hernia,  femoral,  diagnosis  of. 106 

Hernia,  femoral,  prognosis  of. 107 

Hernia,  femoral,  symptoms  of 105 

Hernia,  femoral,  treatment  of. 108 

Hernia,  funiculated 88 

Hernia,  gravity  of. 12 

Hernia,  Hesselbach's ^ 108 

Hernia,  hypochondriacal 14-120 

Hernia,  idiopathic 16 

Hernia,  impacted 16-75 

Hernia,  impacted,  symptoms  of. 75 

Hernia,  impacted,  treatment  of. 76 

Hernia,  incarcerated 76 

Hernia,  incarcerated,  causes  of. 77 

Hernia,  incarcerated,  symptoms  of 76 

Hernia,  treatment  of. 77 

Hernia,  inciting  causes  of 21 

Hernia,  incomplete 12 

Hernia,  infantilis 16-89 

Hernia,  inflamed ,, 74 

Hernia,  inflamed,  causes  of. 75 

Hernia,  inflamed,  symptoms  of. 74 

Hernia,  inflamed,  treatment  of. 75 

Hernia  inguinalis 14-86 

Hernia,  inguino-scrotal 89 

Hernia,  inguino-crural 90 

Hernia,  invaginal 14-122 

Hernia,  irreducible 16-70 

Hernia,  irreducible,  cause  of. 70 

Hernia,  irreducible,  diagnosis  of. 92 

Hernia,  irreducible,  prognosis  of. 70 

Hernia,  irreducible,  treatment  of. 70-71 

Hernia,  ischiatic 14-113 

Hernia,  labial 14-112 


INDEX.  203 

PAGE 

Hernia,  ligamentatic 16-88 

Hernia,  lumbral 14-119 

Hernia,  mortality  from 11 

Hernia,  non-congenital 12 

Hernia,  oblique 12 

Hernia,  obturator 14-109 

Hernia,  perineal 14-111 

Hernia,  phrenic  (see  diaphragmatic) 

Hernia,  predisposing  causes  of. 21 

Hernia,  pulmonalis 9 

Hernia,  pudendal 112 

Hernia,  radical  cure  of. 34 

Hernia,  radical  cure  of,  Agnew's  method 41 

Hernia,  radical  cure  of,  Armsby's  method 42 

Hernia,  radical  cure  of,  author's  method 48 

Hernia,  radical  cure  of,  author's  method,  general  remarks  on 52 

Hernia,  radical  cure  of,  author's  method,  statistical  i-esultsof 67 

Hernia,  radical  cure  of,  Belma's  method 37 

Hernia,  radical  cure  of,  Bonnet's  method 43 

Hernia,  radical  cure  of,  Beckwith's  method 45 

Hernia,  radical  cure  of,  Gerdy's  method 37 

Hernia,  radical  cure  of,  Guerin's  method 43 

Hernia,  radical  cure  of,  method  by  esposure  of  sack 37 

Hernia,  radical  cure  of,  Mosmer's  method 42 

Hernia,  radical  cure  of  reduced  inguinal 103 

Hernia,  radical  cure  of,  Pancoast's  method  and  results 44 

Hernia,  radical  cure  of,  process  by  injection  of  sack 44 

Hernia,  radical  cure  of,  process  by  hare-lip  suture 45 

Hernia,  radical  cure  of,  process  by  ligature 43 

Hernia,  radical  cure  of,  process  by  plugging  and  invagination 37 

Hernia,  radical  cure  of,  process  by  removal  of  sac 37 

Hernia,  radical  cure  of,  process  by  scarifying  the  neck  and  compression 43 

Hernia,  radical  cure  of,  process  by  subcutaneous  suture  with  braid 46 

Hernia,  radical  cure  of,  Eothmuud's  method 40 

Hernia,  radical  cure  of,  Eigg's  method 42 

Hernia,  radical  cure  of,  Pvigg's  method,  remarks  on 44 

Hernia,  radical  cure  of,  Wurtzer's  method 38 

Hernia,  radical  cure  of.  Wood's  method  (John  Wood,  of  London) 43 

Hernia,  radical  cure  of.  Wood's  method  (Thomas  Wood,  of  Cincinnati) 46 

Hernia,  rectal 14 

Hernia,  reducible 16-25 

Hernia,  reducible,  diagnosis  of. 91 

Hernia,  reducible,  symptomatolology  of. 25 

Hernia,  reducible,  treatment  of. 26 

Hernia,  scleroticse 9 

Hernia,  scrotal 14-88 

Hernia,  sizes  of. 1^ 

Hernia,  spermatic 88 

Hernia,  s^^rangulated 16-77 

Hernia,  strangulated,  treatment  of 78 

Hernia,  structure  of. 23 

Hernia,  traumatic 16 

Hernia,  umbilical 14-114 


204  INDEX. 

PAGE 

Hernia,  raginal 14-118 

Hernia,  vesical 9 

Hernial  sack 23 

Hernial  sack,  contents  of. 16 

Herniotomy 80-109 

Herniotomy,  Petit's  method  of. 82 

Herniotomy,  Gay's  method  of 83 

Hernias  of  particular  regions 85 

Hernias  of  the  epigastric  region 119 

Hernias  of  the  hypogastric  region 86 

Hernias  of  the  mesogastric  region 114 

Hypochondriacal  hernia 14r-120 

Idiopathic  hernia l6 

Impacted  hernia 16-75 

Incarcerated  hernia 76 

Incomjalete  hernia 12 

Infantile  hernia , 16-89 

Inferior  hernias  of  the  pelvic  region Ill 

Inflamed  hernia 74 

Inguinal  hernia 14-86 

Intestinal  hernia 121 

Invaginal  hernia 14-122 

Intussusception 14^122 

Irreducible  hernia 16-70 

Irreducible  hernia,  diagnosis  of. 92 

Ischiatic  hernia 14-113 

Labial  hernia 14-ll2 

Ligamentatic  hernia 16-88 

Lumb.ral  hernia 14^119 

Marriage  as  a  predisposing  cause. of  hernia 21 

Mesocolonocele , 16 

Mobility  of  tumor  in  hernia 16 

Needle,  Prof.  Dowell's,  for  radical  cure  of  hernia 49 

Non-congenital  hernia 12 

Obesity  as  a  predisposing  cause  of  hernia 21 

Oblique  hernia 12 

Obturator  hernia 14-109 

Operations  by  author's  method 59 

Operations  by  author's  method,  important  jioints  in 69 

Operations  by  author's  method,  reports  of  cases 58-124 

Operations  by  author's  method,  statistical  results  of. 67 

Ovarian  tumor  as  a  predisposing  cause  of  hernia 21 

Ovariocele 16 

Perineal  hernia 14-111 

Phrenic  hernia 14-112 

Proportions  of  deaths  from  hernia  to  deaths  from  other  causes 11 

Proportions  of  deaths  from  hernia  in  male  and  female 12 


INDEX.  205 

PAGE 

Proportions  of  deaths  from  hernia  to  population 11 

Pudendal  hernia , 112 

Punctures  of  surgical  instruments  as  a  predisposing  cause  of  hernia 21 

Radical  cure  of  hernia 34 

Rectal  hernia 14 

Reducible  hernia 16-25 

Reducible  hernia,  diagnosis  of. 91 

Relaxation  of  the  muscles  and  rings  as  a  predisposing  cause  of  hernia 21 

Sex  as  a  predisposing  cause  of  hernia 21 

Special  hernias 85 

Scrotal  hernia 11-88 

Symptomatology  of  reducible  hernia 25 

Table,  dycotal,  of  hernia..... 18 

Table  of  exemptions  from  hernia 11 

Table  of  mortality  from  hernia ,  11 

Table  of  London  Truss  Company,  on  age  and  sex  in  hernia..... 22 

Table  of  oi^erations  for  radical  cure  of  hernia  by  subcutaneous  suture 125 

Traumatic  hernia , , , 16 

Trusses,  illustrations  of. 29,  30,  31,  33,  35,  103,  113,  116 

Umbilical  hernia 14-112 

Vaginal  hernia 14-112 

Ventral  hernia 14-118 

Vesicocele 16 

Viscerocele. „ 16 


INDEX  TO  THE  SECOND  PART. 

CONTEIBOTIONS  TO  OPERATIVE  SUKGERY  AND  NEW  SURGICAL  INSTRUMENTS. 


PAGE 

Arrow  extractor 196 

Artificial  anus,  a  new  instrument  for  the  removal  of  septum  in 123 

Catheter,  male.  Prof.  Dowell's 162 

Dislocation  of  phalanges,  mode  of  reduction  of 193 

Dislocation  of  head  of  radius  without  fracture  of  ulna,  new  diagnostic  symptom  of  194 
Dislocation  of  the  humerus  (scapulo-humeral) 189 

Excision  of  osteo-fibroid  tumor  of  inferior  maxillary  bone 197 

Excision  of  fibroid  tumor  of  thigh 199 

Instruments  for  lithotomy  in  the  male 147 

Ligation  of  varicose  vein  with  a  shuttle  needle 187 

New  instruments,  illustrations  of, 

123,  147,  166,  157,  160,  161,  163,  171,  172,  180,  181,  182,  183,  185,  186,  187,  196 

Prostate  gland,  enlargement  of. 181 

Prostate  gland,  case  of  suppuration  of. 183 

Report  of  cases  operated  on  by  lithotomy  instruments  of  author's  invention 148 

Speculum,  Prof.  Dowell's 184 

Stricture  of  the  urethra 152 

Stricture  of  the  urethra,  treatment  of 156 

Stricture  of  the  urethra,  general  remarks  on 170 

Table  of  operations  by  Prof.  Dowell,  for  impermeable  stricture 166 

Table  of  operations  by  Prof.  Dowell,  for  fistula 168 

Urethra-meter,  Dr.  Otis' 171 

Urethrotome,  Dr.  Gouley's 172 

Urinary  calculi,  causes  of 127 

206 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  621  D75  C.1 

A  treatise  on  hernia 
lllll 


2002098253 


